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UNITED STATES OF AMERICA. 



LECTURES 



DISEASES OF THE NERVOUS SYSTEM, 



ESPECIALLY IN WOMEN. 



./' BY 

S. WEIR MITCHELL, M.D., 

MEMBER OF THE NATIONAL ACADEMY OF SCIENCES; 

PHYSICIAN TO THE ORTHOPAEDIC HOSPITAL, AND INFIRMARY FOR DISEASES OF THE 

NERVOUS SYSTEM ; 

YICE-PRESIDENT OF THE PHILADELPHIA COLLEGE OF PHYSICIANS; 

MEMBER OF THE NEW YORK ACADEMY OF MEDICINE; 

HONORARY CORRESPONDING MEMBER OF THE BRITISH MEDICAL ASSOCIATION | 

HONORARY FELLOW OF THE LONDON MEDICAL SOCIETY; 

FOREIGN ASSOCIATE OF THE ROYAL MEDICAL SOCIETY OF NORWAY : 

AUTHOR OF A TREATISE ON INJURIES OF NERYES, ETC. ETC. 



SECOND EDITION, EEYISED AN D ENLARGED, 

WITH FIVE PLATES. 







PHILADELPHIA 
LEA BROTHERS & CO. 

1885. 



MAR 10 1885* ) 



+\ 



Entered according to the Act of Congress, in the year 1885, by 

LEA BROTHERS & CO., 
in the Office of the Librarian of Congress. All rights reserved. 



DORNAN, PRINTER. 



DEDICATED TO 



J. HUGHLINGS-JACKSON, M.D., F.R.S., 



WITH WARM PERSONAL REGARD, 



IN GRATEFUL ACKNOWLEDGMENT 



HIS SERVICES TO 



THE SCIENCE OF MEDICINE. 



PREFACE TO SECOND EDITION. 



The book has been long out of print, but only 
of late have I found time to prepare a second 
edition. 

I have altered considerably some of the 
early lectures, and have added others on the 
difficulties of diagnosis in hysterical diseases of 
joints, on the relations of hysteria to organic 
disease of the spine, and on hysterical disorders 
of the rectum. 



A* 



PREFACE TO FIRST EDITION. 



The lectures which compose this volume deal 
chiefly with some of the rarer maladies, or forms 
of maladies, of women. Many of them are original 
studies of well-known diseases, and others deal 
with subjects which have been hitherto slighted 
in medical literature or which are almost un- 
known to it. 

I desire to express my thanks for very valuable 
aid to my colleague Dr. Wharton Sinkler, to 
Professor Horatio C. Wood, to Dr. Louis Starr, 
and especially to Dr. Morris J. Lewis. 



CONTENTS. 



LECTUKE I. 

THE PARALYSES OF HYSTERIA. 

PAGE 

Paraplegia — Hemiplegia — Bilateral hemiplegia . . .13 
LECTURE II. 

HYSTERICAL MOTOR ATAXIA — HYSTERICAL PARESIS. 

Briquet's hysterical ataxia — ISTew forms of hysterical ataxia — 
Forms of paresis ......... 39 

LECTURE III. 

MIMICRY OF DISEASE. 

Causes of mimicry — The hysterical state — General nervous- 
ness—General failure of health — Psychic peculiarities- 
Natural mental and moral conditions favoring mimicry of 
disease — Imitative vomiting — Imitative palsy — Mimicry of 
pain — Imitative epilepsy — Imitative meningitis — Epidemic 
of rhythmic chorea . . . . . . . .55 



LECTURE IV. 

MIMICRY OF DISEASE. 



Hysteria in childhood — Simulated vomiting — Simulation of 
hip-joint disease — Autobiographical confessions . . .81 



X CONTENTS. 

LECTURE V. 

PAGE 

UNUSUAL FORMS OF SPASMODIC AFFECTIONS IN WOMEN. 

Rotatory spasms — Functional spasms — Strychnic spasms — 
Spasms on change of position — Local spasms simulating 
tumors — In the pectoral muscles — In the walls of the ab- 
domen — In the gastrocnemius — Hysterical athetosis. . 96 

LECTURE VI. 

TREMOR. 

Hysterical tremor — Nervous tremor with organic disease of 
the spine — Alcoholic tremor in nervous women . . .114 

LECTURE VII. 

CHRONIC SPASMS. 

Chronic spasm with simulation of local injury of ulnar nerve 
— Chronic spasm of leg — Contracture of leg muscles — 
— Treatment of hysterical contractions — Section of tendons 
— Simulated contractions — Simulation of contractions and 
of disease of ulnar nerve- — Chronic spasmodic ptosis . . 123 

LECTURE VIII. 

CHOREA OF CHILDHOOD. 

The relations of the chorea of childhood — To season — To 
climate — To locality — To race — Forms of chorea . . 137 

LECTURE IX. 

HABIT CHOREA. 

Definition — Cases of habit chorea — Relation to chorea of 
childhood — Treatment 156 



CONTENTS. XI 



LECTURE X. 

PAGE 

DISORDERS OF SLEEP IN NERVOUS OR HYSTERICAL PERSONS. 

Sensory shocks — Emotional shocks — Irregular motor dis- 
charges — Nocturnal functional hemiplegia — Respiratory 
failures in sleep . 163 



LECTURE XL 

VASO-MOTOR AND RESPIRATORY DISORDERS IN THE NERVOUS OR 
HYSTERICAL. 

Pulse in hysteria — Agitation of heart followed by apparent 
death — Eccentricities of pulse in the hysterical — Palpita- 
tion of heart with flushing of face — Palpitation of heart 
with pallor of face — Surface ischsemia — Yaso-motor par- 
alysis in the limbs or the face — Extreme vaso-motor 
paralysis of the whole vascular system of the abdominal 
cavity — Respiratory peculiarities of hysteria- — Case of rapid 
respiration in man from wound . . . . . .184 

LECTURE XII. 

HYSTERICAL APHONIA. 

Paralysis of laryngeal muscles — Failure of coordination in 
the various organs which combine to produce speech . . 208 

LECTURE XIII. 

HYSTERICAL JOINTS. 

Typical case- — Hysterical knee with plastic infiltration of con- 
nective tissues outside of the capsule ..... 218 



Xll CONTENTS. 

LECTUREjXIV. 

PAOE 
HYSTERIA AND ORGANIC DISEASE OF THE SPINE. 

Old cases of hysteria — Unusual case with spinal disease . 227 

LECTURE XV. 

GASTRO-INTESTINAL DISORDERS OF HYSTERIA. 

Comparative rarity of hystero-epilepsies in America — 
Difficulty of feeding hysterical women — Troubles as to 
mastication — Forms of dysphagia — Hysterical anorexia — 
Hysterical vomiting — Hysterical fasting .... 238 

LECTURE XVI. 

THE RECTUM AND DEFECATION IN HYSTERIA. 

Irritable rectum — The paretic rectum — Anaesthesia of rectum 
— Incoordination in defecation — Painful rectum — Anal 
spasm . . . . 252 

LECTURE XVII. 

THE TREATMENT OF OBSTINATE CASES OF NERVOUS EXHAUS- 
TION AND HYSTERIA BY SECLUSION, REST, MASSAGE, ELEC- 
TRICITY AND FULL FEEDING. 

Character of cases needing this treatment — Seclusion — 
Nurses — Uterine disease — Ovarian disorders — Seclusion — 
Rest — Massage — Electricity — Mode of feeding . . . 265 



DISEASES 

OF THE 

NERVOUS SYSTEM, 

ESPECIALLY IN WOMEN. 



LECTURE I. 

THE PAEALYSES OF HYSTEKIA. 

The case to which I drew your attention at my 
last clinic is here again, a girl, rather wanting in the 
signs of sexual ripeness, although sixteen years old. 
You will recall the fact that she lost the use of the 
right arm because of having been alarmed. The 
scare brought on what every woman knows as an 
attack of hysterics — our ancestors called it the 
vapors. The girl cried and laughed by turns, and 
then had a slight fit, on coming out of which she 
could no longer lift her right arm, or rather she 
could lift it but a few inches. On finding this to be 
the case, she grew much concerned, and by and by 
could not lift it at all, the idea that it could not be 
raised helping, as is apt to be the case, to make the 
trouble worse. There seems to have been no deceit, 
but perhaps the first feebleness may have been slight, 
and the power of her belief in her want of force 

2 



14 DISEASES OF THE NERVOUS SYSTEM. 

great, and this is rather the more likely since, as you 
saw, I raised the arm and said, " Now you can keep 
it up," which she did. You see that it seems again 
palsied. A new order restores it, and she lifts it 
without much effort, having won a belief in my 
being able to aid her. I send her away with a 
lightly uttered word or two as to the use of the hot 
iron, if she again loses power. The warning may 
answer, or may not. We had a case very like this 
two years ago. I believe it got well. 

We see here among the ill-fed, needy, and wor- 
ried, a good many cases of hysterical loss of power, 
and I meet a yet larger number among women of 
the upper classes, in whom the disease is caused by 
unhappy love affairs, losses of money, and the daily 
fret and wearisomeness of lives which, passing out 
of maidenhood, lack those distinct occupations and 
aims which, in the lives of men, are like the steady- 
ing influence of the fly-wheel in an engine. 

A yet more common cause of hysterical disorder 
is to be met with among the young persons who 
frequent the colleges for women. Every year brings 
me a fair contingent of patients from these schools; 
and I have asked myself over and over why it is that 
these places produce so much disease which ought 
to be avoidable. As our society is constituted, it is 
clear that women must have opened to them the 
higher grades of instruction ; and yet something 
must clearly be done to avoid the penalties which 
hard study, class competitions, and the emotional 
stimulus women bring to their work, are apt to 
produce. 



PARALYSES OF HYSTERIA. 15 

Something might be done by a careful medical 
examination of the fitness of girls entering colleges. 
Their power to work during and just after men- 
struation should be inquired into, and their early 
months of college work should be carefully watched. 
Above all, their eyes ought to be examined, because 
numerous women become ill from the strain of brain- 
work done with imperfect vision. Moreover, these 
inspections should be repeated at reasonable intervals. 

Let me admit in passing that, at Vassar and some 
other schools, the machinery and organization for the 
care of the physical and mental health of students 
exists ; but it does not seem to work satisfactorily. 
The reason is only too clear. The general sense- 
shall I say the prejudices — of such groups of women 
is opposed to conceding the belief held by physi- 
cians that there are in the physiological life of 
women disqualifications for continuous labor of mind. 
Public sentiment is in women's colleges against this 
belief, and acts as a constant goad for women at 
times unfit to use their brains. If ever the horrible 
system of coeducation of the sexes becomes more 
general, this difficulty will, of course, be mischiev- 
ously emphasized by the modest dislike of the weaker 
girls to exhibit, at intervals, signs of failure, or to 
excuse themselves from tasks which they cannot 
competently pursue alongside of the male, who is 
not weighted by the occasional need to plead any 
form of recurrent disability. 

It is my present wish to speak of some of the 
many kinds of hysterical paralysis, and to dwell far 
more freely on methods of treatment than upon 



16 DISEASES OF THE NERVOUS SYSTEM. 

minute details in the natural history of these dis- 
orders. I do this chiefly because as regards treat- 
ment I hold very positive opinions, and because 
these opinions have, I believe, been amply justified 
by happy results, some of which are familiar enough 
to those who have followed my practice. 

The group of instances of lessened power which 
I shall here discuss will include the usual forms of 
hysteric paraplegia and hemiplegia, and that which 
I shall call double hemiplegia. I shall not attempt 
to cover the whole range of hystero-palsies, but seek 
chiefly so to define a certain number as to allow me 
to speak of their treatment. I shall also describe 
four forms of seeming loss of power, only one of 
which is essentially hysterical in nature, and not 
found elsewhere with the same features. I allude 
to hysterical motor ataxia. 

The others are palsy from the rule of an idea, 
general paresis, and consciously mimicked palsy. 

All three of these may be and are seen outside of 
hysteria, but they find in it a fertile soil, and are 
none the easier to treat when they are masking in 
this disguise. 

One of the chief troubles in clearly knowing and 
in dealing with all of these forms of disease is due to 
the fact that in most cases, and to some extent, they 
may exist in union. The case of palsy may be partly 
real, partly pure weakness, partly loss of power from 
want of belief in being able to move; or conscious 
mimicry may be added to palsy or to the forbidding 
influence of a regnant idea, or to the true hysteric 
palsy may be joined ataxy of motion. For such vex- 



PARALYSES OF HYSTERIA. 17 

ing marriages of disorders, and for their offspring of 
doubt, we must be ready and watchful. They make 
the true limits of hysteric lack of power hard to de- 
fine, hard to treat, full of surprises, and unfailing in 
interest and variety. Take this for an instance : You 
have a case of extreme hysteric paresis to treat. As 
a rule, it is readily cured. You predict a clear and 
happy future. As time wears on the mere weakness 
is gone, the limbs are plump again, the cheek red, 
and then you may find, if you have not been careful, 
as I have found, that hidden in the mere weakness 
there is a distinct amount of motor palsy— a mild, 
one-sided loss of power— a true hysteric palsy, and 
not at all easy to cure. I shall pick for you, out of 
my note-books, cases of each of the forms of disease 
I have just spoken of, and shall try to make plain to 
you how I treat them. There were once no cases so 
much dreaded by me. There are now none to which 
I go with so much pleasure. I am sure that I treat 
them to-day with a success I could not once have 
gained, and I think that what success I have had has 
been due to more exact ideas as to what is needed, 
and that unflinching purpose and action which grow 
out of distinct views. 

Let us take first a case of paraplegia — less common 
than hemiplegia and more difficult to relieve. The 
example I shall quote for you is the more interesting 
because of its having ended in death. 

Mrs. C, set. 36, a strong woman, and in all ways 
well, lost by sudden death a child and her husband. 
Thus having cast on her the care of a large estate, 
loaded with many burdens, she began to show excess 

2* 



18 DISEASES OF THE NERVOUS SYSTEM. 

of anxiety as to her affairs, and from being sweet 
of temper became abrupt and full of unreasonable 
doubt as to her advisers. The worry brought with 
it speedy loss of blood globules, and as she was a 
woman who flowed very freely each month, all these 
causes together began to tell. This is the kind of 
thing we see much of in medicine. The books say 
this, that, or the other causes hysteria. In practice 
it is usual to find two or three causes — acting to 
assist one another. This woman was quite ready for 
an outbreak of some form of nerve trouble, when of 
a sudden she met the final blow in the form of a 
telegram. The news it bore was neither good nor 
ill, but by evil luck the writing looked like that of 
her dead husband, and she began to laugh with that 
strange want of appropriateness in emotional expres- 
sion so common in the nervous. Awaking next day 
her legs seemed heavy, which caused her great alarm. 
At once, as she told me, the fear of palsy arose in 
her mind, and haunted her the more as, day by day, 
the feebleness grew worse. She was in Germany 
when taken ill, and seems to have been looked upon 
as suffering from an organic malady, for she was 
treated with nitrate of silver and the hot iron. Then 
as she failed to get relief anywhere, she was sent 
from one spa to another with a skill which as yet we 
are fortunately far from being able to reach. 

St. Moritz, Schwalbach, Vichy, Loueche, and 
springs of less note, had each their turn, after the 
European fashion, until, in despair, she was carried 
back to America, where I saw her often and until 
the close of her life, 



PARALYSES OF HYSTERIA. 19 

This was what I found : A woman of 35, height 
5 feet 2 inches, weight 170 lbs., flabby, and thin- 
blooded, with healthy heart, lungs, and kidneys. On 
the left side of the vagina was felt a tumor about the 
size of a walnut. It was very tender, and firm pres- 
sure on it gave rise to nausea and distress down the 
left leg. I had no doubt that this growth was a dis- 
placed ovary, but despite this change of place, the 
left iliac fossa, both the skin and the parts reached 
by deeper pressure, was tender to touch. Was it 
ovarian tenderness ? Hardly, in this case. I have 
been told by Dr. Goodell that he has seen this same 
sensitiveness in other instances where the ovary had 
been displaced, and probably too much has been and 
is made of this symptom. The tenderness in Mrs. 
C.'s case was isolated, as is not unusual, and all about 
it up to the waist and down to the feet the bod} 7 was 
without sense of touch or pain, or of heat and cold. 
In tracing this defect upwards it was found to cover 
the left breast, but this was so to-day, and then to- 
morrow it was less, the upper limit ranging from the 
navel to the left armpit. 

Motor power was failing when I first saw her, but 
this had been the case before, and had been followed 
by a change for the better. 

The plan pursued in treating the case was one to 
which I groped my way a few years ago. My patient 
was very thin-blooded, and yet very fat. Such cases, 
for some reason not clear to me, are more hard to 
redden than are those of thin people in like states of 
blood. But if you can safely cause these persons to 
lose flesh, as they are helped to remake it, you may 



20 DISEASES OF THE NERVOUS SYSTEM. 

sometimes redden them with ease, and to raise the 
number of blood globules to the normal is usually to 
lift a woman above that low level of health, which 
is one, at least, of the factors of hysteria. 

Mrs. C. was, when first seen by me, sitting up most 
of the day, and sewing, writing, and the like, when 
not too nervous. I put her in bed, and employing 
as a diet milk alone, mixed with a little rice-water or 
barley-water, I began to lessen the amount given, 
until, using less than a quart a day, her weight fell 
off at the rate of about a quarter to a half pound a 
day. When she showed signs of weakness I added 
beef soup to the diet for a day or two, and thus in 
one month brought down her weight some twenty- 
four pounds. This could not with safety have been 
so quickly done had not the patient have been kept 
in bed. Then the milk was by degrees increased. 
Eaw beef and vegetables were added, malt extract 
was used before meals, a little red wine or champagne 
was allowed, and iron was given freely, the feeding 
being frequent. When I made the increase in diet 
I began to arouse sensation by the use of the wire 
brush and induction currents. 

Now in common palsies, or in those from nerve 
wounds, feeling is apt to come back first, motion 
last; but in hysteric palsies, as I think, the gain in 
active motion may go on, and even reach a useful 
amount while yet the lack of feeling rests as it was 
when the treatment began. Just this change took 
place in Mrs. C. : She grew brighter, and more 
happy, gained in color and flesh, and began to move 
her legs. In a month after she reached full diet she 



PARALYSES OF HYSTEEIA. 21 

could walk with some trouble, and about this time 
the sense of touch showed signs of betterment, but 
the power to feel pain was unchanged, and, in fact, 
was never complete in the left leg. 

Next began a plan of steady, urgent calls upon her 
for increase of the use of her limbs, so that before 
long she was able to walk out of doors. At this point 
I fear there was a mistake made in the treatment. 
Thinking the battle won I pushed her too hard, and 
one day after walking much further than usual she 
felt an excess of fatigue. Returning home she gave 
out of a sudden, and the morning after was again 
hardly able to stir either leg. I may pause here to 
repeat as to this matter a warning I have often given. 
It is to urge on you the utmost care as to allowing a 
hysterical patient on the way to health — I mean, of 
course, one who has lost power — to do more each 
day than fulfil the ordered task of that day. Most 
cases of hystero-palsies are easily tired, and it is 
almost sure to be the case that they cannot make a 
long effort without showing the effect in some way; 
moreover the mental results of extreme tire are to be 
feared, because any positive, real sensation is apt to 
become the peg, so to speak, on which the patient 
may hang the complement of a larger and less real 
sensation. 

More slowly this time Mrs. C. got back some con- 
trol over her movements, but at a certain point the 
gain ceased, and we made no further progress, nor 
did this surprise me. Hysterical paraplegia is, as I 
have said, more hard to cure than any other hys- 
terical trouble except, perhaps, multiple contractures, 



22 DISEASES OF THE NERVOUS SYSTEM. 

and I felt that I had done well to win what I had 
won. 

About six months later this lady died after a brief 
illness, w r hich seemed to me more like a sudden and 
complete palsy of the pneumogastric nerves than 
anything else. No examination post mortem was 
allowed. I have seen three deaths in hysteria; all 
were abrupt, and two were due to acute congestion 
of the kidneys. 

The following case resulted more happily: The 
patient, a woman get. 18 years, had been in good 
health. Her paraplegia was caused by seeing her 
father seriously injured by a fall from a horse. She 
became feeble, ceased to eat sufficiently, and in a 
week was unable to lift hand or foot. She w r as 
brought to me six months later, and w r as then a rosy 
girl of eighteen, not wasted, but presenting a singular 
flabbiness of the muscular masses. The loss of power 
in the legs and feet was so complete that, except in 
the left foot, no motion could be seen. The hands 
were so feeble as to be useless, although all the 
fingers could be moved. Even the neck w r as too 
weak to sustain the head. I had never seen the loss 
of power in hysteria so complete. That of sensation 
was not less so. The face was on both sides defective 
in power to feel pain or touch, or change of tem- 
perature, yet smell, taste, and hearing were as in 
health. I expected to observe some notable func- 
tional disturbance in the eyes, and therefore asked 
Dr. ¥m, Thomson to see her. The most elaborate 
examination by this expert ophthalmologist failed to 
show the existence of even the slightest defect of 



PARALYSES OF HYSTERIA. 23 

color-sense, or, in fact, anything except hyperme- 
tropic astigmatism. Below the face there was no 
ability to feel pain. The sense of touch was lessened 
in acuteness, but not lost. The power to localize an 
impression was impaired, and the sense of tempera- 
tures lost. I should have said that beneath the skin 
there was some feeling. On applying to the nipple 
the bare metal poles of the secondary current of an 
induction coil — a severe test- — no signal of pain ap- 
peared ; but, when two needles were carried through 
the skin, and a strong current passed between them, 
some pain was felt. Over the dorsal and cervical 
spine — that is, from the third cervical to the tenth 
dorsal spine — was a space about an inch wide in 
which pin-pricks could be readily felt. Elsewhere the 
needles used caused no more expression of pain than 
if the woman's flesh had been a pincushion, and no 
bleeding followed their use. As there was constant 
regurgitation of strongly acidulated food after each 
of the large meals she took, she was placed on the 
exclusive use of milk containing two grains of bi- 
carbonate of soda to the ounce. This, w T ith massage 
and electricity, and such training as I shall describe 
at another place, triumphed after two months, and 
she became able to eat, sleep, and walk, much as 
others do. Nevertheless, the analgesia remained 
nearly the same in the legs as at first, although it 
disappeared above the waist almost entirely. The 
sense of touch was not more improved than that of 
pain, and this [was as stated when she had become 
well enough to walk two miles. She seems uncon- 
scious of this continued defect, and my previous 



24 DISEASES OF THE NERVOUS SYSTEM. 

experience teaches me to hope that by degrees the 
analgesia will disappear. In fact, the most useful 
lesson we can draw from this and other like cases is 
the fact that full volitional control may return while 
the sense of touch or of pain remains greatly im- 
paired. Once set the patient usefully afoot, and we 
shall do well to cease to call attention to the con- 
tinuance of the sensory failure. Secure to such cases 
a quiet, unemotional life, and with the renewal of 
healthy nutritive functions, the sensory failures will 
in turn cease to exist. 1 

Of that more common type, the palsies of one side 
of the body, you have seen a number. In this 
country, at least, they are more frequent than the 
paraplegias; less hard to cure, but quite lasting 
enough to make you cautious as to what you predict 
about their future. Where they occur in the feeble 
and thin-blooded, who have by degrees grown emo- 
tional, tearful, and weak of will, you may have more 
hope of helping them than if they are met with in 
robust people of non-emotional type, in whom the 
usual emotional elements which go to build up this 
temper of mind are wanting, or are small in amount. 
The former offer through the relief of their nutritive 
defects chances of obvious nature ; the latter are apt 
to be bright or even able women, who enlist their 
mental forces in behalf of their symptoms, and treat 
the hated charge of being hysterical with utter 



1 Six months after the above notes were written, I learn that the 
patient whose case I have described above is perfectly well. 

2 I ought, perhaps, to add that these women are usually mobile 
and excitable by nature, prone to laughter more than tears, so that 



PARALYSES OF HYSTERIA. 25 

I cannot leave this subject of hemipalsies of hys- 
teria without a few words as to the ordinary type of 
this disorder. I shall, therefore, sketch for you 
somewhat briefly the chief symptoms of hemiplegia 
of hysterical origin. 

This disease may come on slowly, and during the 
varied course of a case of hysteria, or it may arise 
abruptly — in an instant, even — in women known or 
not suspected to be hysterical, owing to some pro- 
found emotion or to an accident, such as a fall or a 
wound. It is often of such insidious development 
that its presence, when mild, is a thing rather to be 
found by looking for it than of such a nature as to 
be forced upon the attention of the observer. It is 
excessively rare to see it as complete as we see a 
hemiplegia of organic origin. Nearly always — I 
might venture to say always — it is associated with 
some loss or disturbance of sensation. More often 
this latter symptom is the dominant one, and the 
lack of power merely amounts to a paresis or incom- 
plete palsy. 

Unlike the hemipalsy of cerebral and organic 
cause, hysterical half-palsies involve more or less all 
of one side of the body, excepting the face ; but in a 
few rare cases the neck is distinctly affected, while 
usually when the case is incomplete, it is the leg 
which suffers most, both as to sensation and motion. 

Apart from the fact that the face escapes, there 
are other symptoms which differentiate these losses 

it is hardly exact to say they are not emotional. Their form of too 
ready emotional disturbance lies merely in an unusual direction for 
the victims of hysteria. 

3 



26 DISEASES OF THE NERVOUS SYSTEM. 

of power from those which are due to clots or emboli, 
and a knowledge of which enables us to diagnosticate 
the case with sufficient ease, as arising from hysteria. 
As to localitj^, in Briquet's cases there were 70 on 
the left to 20 on the right; in my own note-books, I 
find the proportion as 4 left to 1 right. The amount 
of loss of power is often quite definite, but in other 
cases it varies in degree, and from day to day, within 
wider ranges than we see in palsies of organic birth. 

It is exceedingly rare to see unilateral loss of 
power in hysteria without distinct defects of feeling. 

Sensation is disturbed, lessened, or lost either 
throughout the one-half of the body or in varying 
amounts over this space, and in the face, as a rule, 
less than elsewhere. In rare cases, the sensibility 
improves very near the middle line of the body. In 
some instances no feeling exists; more often sense 
of touch and power to localize sensations remains 
with profound analgesia, and often also with lack of 
power to tell heat from cold. In bad cases, espe- 
cially if very feeble, the vision is subject to blurring, 
or the eye on the affected side undergoes the curi- 
ous loss of color-sense described by Galezowsky; 
although in the milder cases, and in some grave 
ones, this is assuredly not a constant symptom. 
Deafness is much more rare, but has been seen 
twice within a year in this clinic by Dr. Sinkler. 

Charcot and Dr. Buzzard both state that the patel- 
lar tendon reflex is exaggerated on the side of the 
palsy, and the latter that the ankle clonus may at 
times be met with. In the last three cases I have 
seen of hysterical hemipalsy the patellar tendon reflex 



PAKALYSES OF HYSTERIA. 27 

was increased on the affected side. In two others 
it was notably lessened, as was the case in the girl 
present at my last clinic, in whom it was only possible 
to be sure that this symptom existed at all by grasp- 
ing the muscles with one hand while the blow was 
struck. In another case the flexors responded and 
not the extensors ; and in yet another, with an exag- 
gerated reflex, there was also a sharp contraction of 
the adductors on both sides. 

In a case now under my care there is slight con- 
tracture of the calf muscles, and the heel is thus 
drawn up. The attempt to evolve ankle clonus is 
successful, but in a few seconds the extensor muscles 
of the thigh jerk or twitch, and next the foot of the 
sound side exhibits a beautiful example of ankle 
clonus. 

A good deal has been said as to ovarian tender- 
ness in hysterical hemiansesthesia and in the yet 
graver hysteric states. I put less stress on it than 
is done by the school of Salpetriere. Often in hemi- 
palsies of the kind we are now discussing there is 
tenderness over a region which has by a sort of un- 
questioning agreement been called ovarian, and which 
begins at the groin, and is of variable extent. Some- 
times there is no such sensitiveness, or else possibly 
it extends above the navel, or it is felt only on deep 
pressure, and in another case only upon pinching of 
the skin. Then again, it may exist when one or 
both ovaries are gone; so that while we must admit 
this sesthogenetic region as common in hysteria, we 
must not too readily feel sure that its sensitiveness 
is related directly to the little ovary beneath it. 



28 DISEASES OF THE NERVOUS SYSTEM. 

It has been shown of late that defects of the spe- 
cial senses, once looked upon as peculiar to hysterical 
hemiplegia, are to be met with also in palsies of 
organic cause. I have elsewhere in this volume 
spoken of ischsemia of the skin as being found 
in other than hysteric analgesia. Within a few 
months 1 1 have called attention to yet another resem- 
blance between palsies of organic and of functional 
birth; and have shown that in hysterical hemiplegia 
we may meet with unilateral swelling analogous to 
that seen in like palsies due to clots or emboli. The 
oedema of organic brain disease w^hen present at 
all is pretty constant ; that of hysteria varies enor- 
mously, and is influenced by menstruation, exercise, 
and emotional disturbances. It may be slight, or 
may surpass by far any like disorder to be met with 
in hemiplegia due to clot or embolus. There is also 
something peculiar about the swelling. In places it 
is clearly cedematous ; but in others no pit can be 
made by pressure, or else the most prolonged pres- 
sure is needed to produce this sign of oedema. 

In the early stages of hysterical palsies the elec- 
trical reactions are normal; but after a time changes 
occur in a certain proportion of cases. These are 
rarely such as indicate those degenerative changes 
which force upon us the inference that the spinal 
cord has undergone some destructive change. More 
commonly long-contracted limbs, suffering from the 
atrophy of disuse, present merely a relative lessening 
in response to maximal electrical excitations. Some- 

1 Am. Journ. Med. Sci., July. 1884. Unilateral Swelling of 
Hysterical Hemiplegia. 



PAKALYSES OF HYSTERIA. 29 

times we meet with eccentric phenomena which 
demand further study. Thus, as is well known, it 
is common to find the healthy response of muscles 
to electricity delayed a little, or to see it increase 
after the current has been used a few moments. 
Now, in some hysterical cases, the only peculiarity 
is an enormous increase in the length of this period. 
I saw this well illustrated some time ago in a chronic 
case of horrible rhythmic spasms of the arms, with 
palsy of sense and motion in the legs. Dr. Yarrow, 
the attending physician, studied with me the electric 
state, which was curious. When with slow or rapid 
breaking of circuit (induced currents) we tested the 
leg muscles, the currents, although unbearable by 
us, caused no motion until they had been steadily 
applied for from two to three minutes to any one 
muscle. 

There are, therefore, numerous points of likeness 
between palsies of organic cause and those due to 
hysteria. Nevertheless, the differential diagnosis is 
rarely difficult, and I may add that while I see many 
mistakes made, owing to confounding hysteric para- 
plegias with those of organic cause, I rarely see such 
confusion as regards hysteric hemiplegia. 

The following case, now in the Infirmary, may 
serve as a fair type of this form of paralysis : Miss L., 
a fine, large, ruddy woman of 26 years of age, owes 
her hemipalsy to the shock of a fall from affluence 
to the need to support herself by giving lessons in 
music. Then a succession of deaths fell upon her 
household; and at last, one day, while engaged in 
teaching, she fell asleep, as it were, abruptly, at about 

3* 



30 DISEASES OF THE NERVOUS SYSTEM. 

9 A. M. She was aroused enough to be taken to bed, 
and there remained thirteen hours, in what seemed 
to be profound slumber. After this unusual trouble 
she grew more and more hysterical, and at last came 
under my care. Her organs are, in general, healthy; 
but she has this curious peculiarity, of which she 
seems quite unaware. The pulse varies from 80 to 
95; but the respiration, without seeming to be hur- 
ried or distressed, is never less than 40, and is often 
60 to the minute. 

She has considerable loss of power, with incom- 
plete analgesia, defect of thermal sense, and preserva- 
tion of touch. The face is scarcely affected at all, 
and the senses of sight, smell, and taste are intact. 
There is no ovarian tenderness on either side, and the 
analgesia varies daily, almost hourly, as to extent, 
place, and amount. A mustard plaster or blister, or, 
more remarkably, freezing by rhigolene, will often 
restore feeling over a large space for a few hours or 
for days ; but invariably the next menstrual flow un- 
does whatever good may have been done. I tried the 
" metal cure" in this, as I have tried it over and over 
in other and worse cases ; but, although from it, or 
from glass, cork, wood, or what not, I have obtained 
many times a slight local change in feeling, I have 
never seen this complete, and have never once wit- 
nessed the phenomenon of transfer of the analgesia 
or anaesthesia to the opposite side — a phenomenon 
which seems to be undeniably frequent in the hands 
of as admirable an observer as Charcot. I ought to 
add that my colleague, Dr. Sinkler, has not been in 



PARALYSES OF HYSTERIA. 31 

this matter more fortunate than I, although he has, I 
believe, studied several cases from this point of view. 
The patient I have mentioned has many other hys- 
terical troubles, and, being quite rosy and stout, will 
be a difficult case to deal with. It is interesting to 
learn that until this girl came here neither she nor 
her medical attendants were aware that she had any 
loss of feeling. 

The temperature of the left, the affected leg, is 
normal, or the same as the other, and pin-pricks fail 
to bleed at any part of the limb where there is 
lessened feeling. The tendon reflex of the patella is 
remarkably exaggerated on the palsied side, but 
there is no ankle clonus. Under use of good diet 
and tonics this girl is gaining color and weight, 
while by a succession of irritants, chiefly the wire- 
brush and induction currents, the sensation has been 
more and more successfully restored, so that the last 
menstrual flow, which commonly leaves her much 
worse, has been less disastrous than usual. 

I shall not trouble you further with details of this 
the most common type of hysteric hemiplegia, but 
pass on to one of the forms not well described as yet, 
and which I shall, in advance, venture to call double 
hemiplegia. This, as we shall presently see, is not 
merely another name for paraplegia. 

Miss B. 9 a sturdy, handsome girl, ?et. 16 years, 
had a series of ills, one on another, from time to 
time. The first sign of trouble was twitches of the 
eyelids, and tears on reading ; then there was a pause 
of two years. The next disturbance was a noisy and 
obstinate hiccup, during which both iliac fossoe be- 



32 DISEASES OF THE NERVOUS SYSTEM. 

came tender, and a single hypodermic use of morphia 
was followed by convulsions. Next came hysteric 
loss of desire for food, nausea, pains in the left arm 
and leg, and spasm of the vessels in the left leg, so 
that it became white and cold. Up to this time she 
still walked out; but in the summer of 1878 the use 
of galvanism is said to have been followed by sick 
stomach and loss of power to stand. In the autumn 
she got rid of immense masses of hard feces, when 
all the symptoms improved for a time. The next 
winter was passed in bed, vomiting a good deal; 
eating little; the bowels very hard to move; the 
urine passed every hour. About this time, also, she 
began to shun light, and came at last to living, with 
covered eyes, in a darkened room. When I saw 
this young lady I was struck with the thorough type 
of the emotional hysteric person she showed; nor 
from the usual weak will to the usual love of sym- 
pathy was there any tint wanting to the picture. I 
watched her for a few days without ordering treat- 
ment, until I learned all I could of herself, her his- 
tory, her home-life, her pursuits, her ambitions, and 
her mental powers. Then a talk with a watchful 
nurse helped me further, and I saw clearly that I 
had to do not with a clever woman who may be won 
over, and who is flattered by the tribute paid to her 
mind when you insist that to cure her she must be 
made to understand and agree with you, but with a 
child who, to be made well, had to be calmly and 
firmly ruled, and held day by day to rigid account. 
She was at once shut up, with a good nurse, and kept 
at rest in bed, not being allowed to use her hands 



PARALYSES OF HYSTERIA. 33 

even to feed herself. As she had been able to knit 
and sew, and be read to, and to receive many visits, 
the sense of the irksomeness of the treatment soon 
made her eager to do anything I wished. Then 
began a system of bribes. She was told that if she 
could learn to bear the light she would be able to be 
read to, but that the nurse could not be allowed to 
strain her eyes. It would have been easy to open 
the windows and say you must bear the light, but if 
she herself gained this point of vantage, it would 
have the great value of being a self-conquest. In a 
few clays I found the sunlight bright in her room. 
Then she was asked to overcome the habit of regur- 
gitating her food. One or two scoldings, some show 
of disgust, and the promise that she should soon feed 
herself if she obeyed my wishes, helped us through 
with this. There were relapses; but as I found she 
hated milk I felt forced to put her back on the milk 
diet we began with whenever she threw up a meal, 
so that before long we heard no more of the vomit- 
ing; meanwhile the steady feeding and the use of 
massage, and local muscle treatment by electricity, 
began to show in a gain of flesh and color and firm- 
ness of muscle. She was now very weary of this 
unending quiet, and the time for education of the 
motor powers seemed to have come. Her loss of 
motion on the left side was very marked, and there 
was complete want of power to feel pain or to tell 
heat from cold; yet I could not make out any loss 
of vision or of color-sense. The touch was not per- 
fect, but she knew fairly well where she was touched, 
although she could not be tickled. 



34 DISEASES OF THE NERVOUS SYSTEM. 

As regards the pain-sense, there was one very 
curious point to which I have already alluded. As 
the needle came within an inch or two of the middle 
line of the body, both at the back and front, it was 
felt, and the better felt the nearer it came to this 
line ; nor do I recall having met with this fact in 
any case of palsy from organic cause. The right 
side of the body was palsied in a less degree, and 
only as to motion, the leg far more than the arm. 
The same was the case on the left side as regards all 
the forms in which the functions were deficient. 
Now as this case grew better the right side became 
entirely well first, leaving the left hemiplegia as 
before, so that I have reason to speak of the whole 
loss as being due to a double hemiplegia. In other 
cases I have seen a general loss of sense and motion, 
and observed entire relief on the right side, leaving 
only a hemiplegia of the left. 

My patient had some wasting of the left leg, and 
less good electro-muscular reaction on the left, but 
no pain on that side from any form of current. The 
tendon reflex below T the knee-pan was good on the 
right, and also on the left ; but, what was new to me, 
the jerk was sometimes due to the extensors, and 
sometimes due to the flexors, the extensors in the 
latter case not seeming to move at all. Here was 
another of the oddities of this most strange disorder. 

As is usual, she moved her limbs best while in 
bed ; and showed, when I came to let her sit up, or 
stand, the loss of balancing power which is seen in 
all grave hysteric palsies, and is, indeed, almost a 
sure sign of the parentage of the disease. 



PARALYSES OF HYSTERIA. 35 

I have often asked you to note another point which 
this case showed very well. You ask the patient to 
raise the leg; it is lifted an inch. You insist on 
effort ; it is lifted higher ; or, if a great effort be 
made, the motion consists of a series of lifts and 
pauses. 

The reliefs of distinct hystero-palsies are said to 
be often abrupt. Under emotion or return of the 
menstrual flow, or on an order from some one, the 
patient gets well. I must say that in hystero-hemi- 
plegia and paraplegia, with loss of feeling, I have 
not been so happy as to see these delightful cures. 
In hysteria with mere paresis, in the palsies from 
belief, or from a ruling idea, I have seen such results 
many times. Neither do I believe that all hysteria 
is after a time within control of the sick person; nor 
that she can in all instances run away in case of a 
fire, according to a popular belief. In fact, I have 
now in my care a lady who was so tested by chance, 
and who utterly failed to do more than fall down in 
her effort to escape from a house on fire. 

In fact, profound emotions may w T ork either way 
for good or for ill, and no human sagacity will suf- 
fice to enable us to predict results. The evil is quite 
as likely to be prominent as the good, and at all 
events you may rest assured that emotions are some- 
what unmanageable and unreliable as therapeutic 
agents. 

I have felt the need to say this, even if too briefly, 
because I must add that the cures of these cases are 
to be made by a slow, steady, hopeful training of the 
will powers through every-day effort, which needs 



36 DISEASES OF THE NERVOUS SYSTEM. 

some caution not to err in the way of excess. A 
little nervousness is a bad sign, and it is well each 
day to attempt a very little — no matter how little if 
only we succeed, and can make the patient see it. I 
shall in another place be more precise as to the means 
used. Enough to say of this case that it w r ent on 
slowly gaining ground, and was under my care a 
year before the patient could walk well enough on 
crutches to go home with a cheerful future. It was 
not a brilliant case, and it taxed nurse and doctor to 
the uttermost — a case urged and scolded, and teased 
and bribed, and decoyed along the road to health; 
but this is what it means to treat hysteria. There is 
no short cut; no royal road. 

Let us take another case. It was as much like the 
last as it could well be. The patient, Miss C. P., set. 
18 years, the child of wealthy parents, came to me 
last year from Indiana. The motor losses were very 
remarkable, and, as in the last case, it was the left 
side which suffered most. She was unable to lift 
the left leg, or flex or extend the foot, so that below 
the knee there was motion in the toes alone. The 
left arm preserved all movements, but all alike were 
feeble. The right side was more symmetrically dis- 
ordered, so that almost every muscle of the leg and 
arm was partially paralyzed. Sensation was lost for 
pain on the left side, save as to the belly and breast, 
where it seemed to be good, while in the face and 
neck it was lessened. Sense of temperature was 
more absolutely lost over the whole side than is com- 
mon; and touch, not quite lost anywhere, was dis- 
turbed or lessened in irregular spaces. On the right 



PAKALYSES OF HYSTERIA. 37 

side sense of pain was lessened in the arm and lost 
in the leg, while touch and the thermal sense were 
well preserved. There was one matter in which this 
case differed from the last one, and this changed my 
whole manner of dealing with the malady. My new 
patient was a clear-headed, well-educated girl, who 
had once had a vigorous will. She was described to 
me as unselfish, thoughtful, and intelligent, and as a 
woman only brought down to a state of hysteria by 
long illness and the want of helpful advice at the 
right moment. She was emotional and ashamed of 
her tears, and honestly hated the whole matter of 
sickness. You will see such hysterical women. You 
will see others whose minds are like the back of a 
piece of needle-work with a baffling absence of pat- 
tern — women with a low, whining, bleating voice 
that is by itself a tell-tale of the kind of will-less 
ataxia which seems to cripple the mind no less than 
the body. These are the hard cases to relieve. But 
to return to my more favorable case. I tried to 
make her see how much the defects of body have 
to do with those of mind, and therefore the need to 
begin by building up the body anew. When, after 
a time, the limbs began to round, and color to come 
back to her pallid cheek, I set her to thinking how 
far the early troubles might have been within her 
control. I assured her that, although she could not 
now overcome at once the results due to habitual 
failure of self-control, repeated efforts would surely 
end in success. She was told that it was like the 
case of a bad temper, easy to hold in check at first, 
but if long unheld at last uncontrollable. It is not 

4 



38 DISEASES OF THE NERVOUS SYSTEM. 

hard to open this point of view to a clever woman. 
You urge this idea from day to day; you ask her to 
try your way. She says she has done so, and then 
you point out that with ill-health success was out of 
the question, while with rising health it might be 
easy. At last you get her to promise to fight every 
desire to cry, or twitch, or grow excited. 

Above all, you teach her the priceless lesson for a 
woman of the value of moods, of the ease with which 
she can get herself into a state of dangerous tension, 
of the necessity of learning, not how to bear a thing, 
but how to approach the idea of bearing it in a state 
of calm. It is a long sermon, but I can only give 
these few pregnant texts. It is always apt to win 
with a woman of intelligence, and the fools are to be 
dealt with by other moral drugs than these, or the 
honest pill must be gilded with timely flattery or 
such better motives as may help it to find the 
woman's conscience, if that is to be stirred at all. 

By and by, as one symptom after another gave 
way before her efforts, she became more and more 
sure that I must be right as to all ; and I have seen 
few cases gain ground with equal speed. Neverthe- 
less a whole year was needed to make her w^ell able 
to take up afresh her full round of social and house- 
hold duties. In fact, even with the best of self-help 
from the patient, the cure of any one of these cases 
is a long and arduous course of education. 



HYSTERICAL MOTOR ATAXIA. 39 



LECTURE II. 

HYSTERICAL MOTOR ATAXIA— HYSTERICAL 
PARESIS. 

The form of disorder to which I shall next direct 
your attention in connection with hysteria is the 
motor ataxia of this disease. It is necessary here to 
be extremely precise, because, as you will see if you 
read Briquet's admirable study of hysteria, he also 
describes a form of hysterical motor ataxia. 

Ataxia, as you well know, means merely disorder 
or irregularity, and when therefore we speak of loco- 
motor ataxia we mean only disordered movement, 
and not of necessity enfeebled movement. The cause 
of the disorder or incoordination thus introduced into 
motor functions may vary. 

In hysteria, so far as I know, there are two forms 
of motor ataxia independent of those associated with 
vertigo. That described by Briquet and Lasegue 
seems to depend upon a loss of sensation in both 
skin and muscles. In Lasegue's case the girl was 
only able, the eyes being closed, to move the limbs 
which were still sensible, but was totally unable to 
move the anaesthetized parts, or to know where they 
were when moved by another person. While see- 
ing, she could walk readily and even without looking 



40 DISEASES OF THE NERVOUS SYSTEM. 

at her feet. 1 In other and similar cases there is 
merely a lack of coordination in complex motor 
acts. 

There is, however, another and a very interesting 
form of hysterical motor ataxia, as yet undescribed, 
which is, I fancy, rather rare in its most perfect type, 
and which may without due care be taken, as was 
posterior sclerosis of the cord long taken, for some 
kind of paralysis. 

The trouble I am about to speak of I find to be 
in some of its degrees very common in hysteria — to 
coexist with many hysteric palsies or paretic states, 
and sometimes, though rarely, to be the prominent 
malady, with almost no loss of voluntary power. 

The hysterical ataxic patient of this class, and I 
shall consider first the nearly pure case, has full feel- 
ing, or may have it, and is quite well able to use the 
limbs more or less freely while lying down. When 
she begins to sit up or kneel or stand, the lack of 
coordinate muscular movements becomes at once 
visible. 

Instantly the patient begins to fall to one side, a 
voluntary effort to redress the disturbed balance 
results in a partial fall to the other side, or back or 
forward, as may chance. The patient seems to be 
unable to judge of the extent to which the balance is 
lost, and also to determine or evolve the amount of 

1 There may be in this something of habit. In the few cases of 
spinal locomotor ataxia which I have seen in women I have been 
struck with the way in which, as their garments habitually hide 
the feet, they managed to dispense with the guiding sight of these 
parts. 



HYSTERICAL MOTOR ATAXIA. 41 

power needed to overcome the defect. The abrupt- 
ness of these efforts at redressing the loss of equi- 
librium appears to show an absence of defect of the 
usual antagonistic activity of opponent muscles. I 
am inclined to suggest as a reasonable theory that 
perhaps a large share of this difficulty may be due to 
a slowness in volitional acts by reason of which the 
mandate reaches the muscle 100 late to be of ready 
service. This is by no means unlikely, for in some 
hystero-palsies I have measured and proved the re- 
tardation of nerve-conduction. Slowness in learning 
the need to move a muscle and slowness in moving 
it would give rise to just such incoordinate action as 
these cases exhibit. The lack of orderly movement 
is chiefly in the neck and trunk, and is made worse, 
like all disorder of motion, by excluding the guiding 
influence of vision. 

This very interesting form of incoordination in 
muscular acts is limited for the most part to the more 
complex movements. It is seen little or least in 
single limb motions, better in sitting or kneeling, 
better still in standing, and best of all in walking. 
It is not due to weakness because it exists in cases 
strong enough to sit, stand, and walk firmly, if only 
power were needed to the efficient accomplishment of 
these acts. Also, while you may find it with general 
or local lack of surface feeling, it is not due to this, 
because anaesthesia of the skin alone is, in the hys- 
terical at least, incompetent to cause ataxia of motion. 
In the confusion and odd grouping of symptoms in 
hysteria, the trouble I have described is apt to be 
overlooked or attributed to coincident conditions, 

4* 



42 DISEASES OF THE NERVOUS SYSTEM. 

It is, therefore, fortunate to find now and then cases 
in which this form of motor disorder occurs almost 
alone, so that we have a chance of studying it without 
being embarrassed by other symptoms. 

I believe that this ataxic state is common in grave 
hysteria, and is to be found often enough in milder 
cases. I think also that some of the cases which are 
attributed too promptly to muscular anaesthesia will 
be found to be free from that defect, and to be due 
to other causes than those to which Briquet has at- 
tributed them. Perhaps it may be that conscience 
of locality will prove a differentiating test, since it 
is said to be lost in the hysterical ataxia of Briquet, 
and is certainly not always lost in the form I have 
here delineated. 

I do not think one could readily confound this 
ataxia of movement with anything else, unless it be 
with one of the rarest of the forms of hysterical 
spasm. The following case is an apt illustration of 
this latter disease which might, perhaps, be well de- 
scribed as alternating spasms, the action of the flexors 
calling the extensors instantly into movement, and 
these in turn summoning the flexors into like activity. 
These semi-spasmodic motions were the more curious 
in the last case I saw, because of the general and pro- 
found paresis which made every volitional effort ex- 
cessively difficult. I may add that there was also a 
contraction of the right leg and a left hemi-ansesthesia 
with fair conscience of the place of a touch. 

The patient, when seated and held up, or even 
when the head alone was unsustained, showed the 
following symptoms : The head or body was pulled 



HYSTERICAL MOTOR ATAXIA. 43 

to one side. At the limit of this motion, or before 
that was reached, it was violently jerked over by the 
opponent muscles, as if their stretching were the sig- 
nal for an explosive act of power. At once, or in a 
moment, the other muscles acted in like fashion, and 
so the head or trunk was thrown about in a strange 
and disorderly manner so long as the patient remained 
upright. The same type of movement extended to 
the legs and arms. These acts were certainly of 
volitional birth, but they were, so to speak, convul- 
sive renderings of natural acts, and were sometimes 
very violent. 

I may add that, notwithstanding the complexity 
of symptoms, with such a loss of memory as necessi- 
tated an entire reeducation, this girl became entirely 
well. 

In place of giving you types of motor ataxia with 
palsy I shall prefer to choose one now in my care, 
and which has the least share of palsy for the largest 
share of incoordination of the muscles. 

Miss B., set. 20, Kentucky, of healthy, living 
parents, in August, 1876, while going home from 
the Centennial Exhibition, caught a slight cold, out 
of which came complete loss of voice for seventeen 
months. In its return it came and went abruptly, 
and was well to-day and gone to-morrow. In Sep- 
tember, 1871, at the Hot Springs, Arkansas, after a 
good deal of worry, she is said to have had headache 
and dizziness, after which of a sudden she lost speech, 
and became unconscious, with her jaws firmly locked. 
The legs and arms were seized with spasms, and 
when they became better had nearly lost touch-sense, 



44 DISEASES OF THE NERVOUS SYSTEM. 

and did not feel pin-pricks. This attack ended in 
weakness and fever, with cold feet and loss of power 
to swallow even saliva. After three weeks she re- 
gained speech, and then again relapsed. She was 
said to have had a typhoid fever, which does not 
seem likely. 

About the fifth week she was found to have lost 
power in the legs. The loss is described as having 
been nearly entire; but by March, 1879, she had re- 
gained a good deal of motion. Since then she has 
been at a standstill. 

In October, I saw Miss B. in bed, a dark-skinned, 
rosy-looking girl, without the least turn to tears or 
undue emotion. I should only have said that her 
manner was quick and excitable. She certainly had 
none of the usual furtive look, and small deceitful- 
nesses of some hysterical girls. Neither was there 
any loss of tendon (patellar) reflex, and the senses of 
pain, of touch, and of heat were perfect. 

While in bed, Miss B. moved all her limbs some- 
what slowly, but with a great deal of power; the 
lift of the leg was done in jerks, as by distinct orders 
of will, but she showed none of the tremor and 
twitching of face and tearful look so common in 
hysteric girls called on for an unusual effort. When 
held up on her knees, she swayed to and fro, always 
falling if not assisted. When somewhat later she 
could stand up, the motor disorder showed still 
better. From head to foot every muscle used to 
preserve the upright posture gave w r ay momently, 
and was braced again by distinct acts of will. The 
rocking motion so caused was curious to see. A 



HYSTERICAL MOTOR ATAXIA. 45 

slight push was sure to upset her, as if she was un- 
able to provide in time enough of power to resist 
the shock and restore the disturbed balance. If I 
warned her of the coming shock, she did far better. 
The touch of a hand greatly aided her, and the 
closing of her eyes made things worse. Nor did 
Miss JB., when standing, appear to have the least 
idea of her balance being in danger until the sway 
of her figure became extreme, when she caught her- 
self up, and with an effort regained her erect position 
only to fall to the other side. There seemed to be a 
lack of appreciation of the failing balance, and a 
slowness in redressing it when lost or in peril. When 
added to this we have complete loss of feeling — 
when skin, bone, joint, and muscle share alike in 
this respect — we have, of course, a still more com- 
plete and a different form of want of power to pre- 
serve the upright posture ; but this is said to be the 
character of the trouble spoken of by Briquet and 
others, and I wished to make it dear that there were 
causes of motor ataxy which did not of need involve 
any lack of tactile sense. 

In Miss B.'s case, little was needed beyond train- 
ing the weak and inapt muscles, because she ate and 
digested well, slept soundly, and was free from pain. 

My first step was to point out to her that, after she 
had made an effort which seemed extreme, another 
forth-putting of will would add to the previous result. 
This seems a simple thing to make clear ; but, if you 
can convince your patient of the fact, it is of great 
service, because then you go on to point out further 
that, perhaps, by a series of trained and aided efforts, 



46 DISEASES OF THE NERVOUS SYSTEM. 

there may be won, bit by bit, a full power of motion. 
To lodge this idea in a woman's mind is at once to 
widen the horizon of hope. How much you gain by 
it depends a little on whether your patient is clever 
and wants to get well, or is silly and prefers the role 
of hysteria; but, after all, the whole mode of treat- 
ment rests on a study of character, or of character 
and hysteria, and a moral diagnosis is the first step 
to take. 

With Miss B., at a standstill for months — bright, 
clever, longing for active life — the idea was as a 
wholesome ferment. The nurse now began to train 
her while in bed to move the legs, one at a time, 
very slowly, but in larger and larger movements, 
with intervals between of a minute or more. 

An order is given to lift the leg ; if it be too weak, 
a finger beneath the ankle aids it, but no attempt 
must be let to fail utterly; as she gets on, the orders 
are to be obeyed more quickly. It is easy to sketch 
out for one's self what such a system should be in its 
details. After it has gone far enough, the patient is 
seated in bed with some support to her spine, and is 
trained to move the head freely. When, in Miss B.'s 
case, she was put on the edge of the bed seated, the 
motor ataxia began to show, so that it took some 
time to overcome this trouble. The next step used 
with me to be a lesson in walking, but of late I find 
it better to teach the girl to creep, which is an easy 
and natural mode of training for the walk. The 
patient has pads tied over her knees, and, lying flat 
on her face on the floor, without skirts, has around 
her a folded sheet. At an order, she tries to rise, 



HYSTERICAL MOTOR ATAXIA. 47 

-> 

helped by the lift of the sheet-belt held by the nurse. 
When she is able to do this, and can gather her legs 
and arms so as to make herself a quadruped, she is 
taught to balance herself, every effort being assisted, 
when needing help, by the nurse standing above her. 
The progress to creeping is easy; then comes the 
lesson of kneeling and pushing a chair ; and, last, 
that of standing in a corner or by a chair. You see 
that, following nature's lessons with docile mind, we 
have treated the woman as nature treats an infant. 
For aid in walking we have three devices : the ex- 
pensive wheel crutch, which can be easily imitated 
by a clever carpenter, being merely a framework 
with rollers so arranged that it includes crutch sup- 
ports. Next, if need be, I use a device which may 
be common, for all I know, but which I have not 
seen elsewhere. It is a pair of crutches with a stout 
half-hoop of metal between and in front of the two. 
This gives a solid support, and, in ataxic cases, is 
very useful as giving a sense of security, and, there- 
fore, of confidence. This crutch-frame is soon re- 
placed by a pair of supports, the bases of which are 
about seven or eight inches long and two broad. 
They may be made like the lower half of a crutch, 
or have two columns of a support set in the base, or 
may be a single cane with broad base; the top in 
any case should have a double curve so as to lie 
easily in the line of the natual slope of the palm 
when resting on such a support. A rubber footing 
gives a little elasticity and a good hold on any form 
of flooring. With such a broad base of support, it 
is quite pleasant to find how soon the patient learns 



48 DISEASES OF THE NERVOUS SYSTEM. 

with its aid to balance herself. A third form of 
support, which I devised two or three years ago, is 
of use in hysteric or in an}^ form of hemiplegia. If 
the left arm be too feeble to aid the left leg by 
grasping a crutch, I resort to the following arrange- 
ment. On the lame side a crutch, having above an 
unusually deep hollow to receive the armpit, is 
fastened to the arm by two straps or by a glove 
riveted to the hand-piece of the crutch, so as that 
the hand, once slipped into it, is pretty firmly held. 
From the crutch a double metal bar curves forward 
and towards the sound side, and ends in a handle 
which is grasped by the sound hand and carried for- 
ward by it. I have found these supports most useful 
in many forms of weakness. In making them, or 
having them made, pray remember that they should 
be made light ; most crutches are too heavy. 

With regard to Miss B., I may add that she got 
well in two months, so as to walk unhelped anywhere, 
and that she is now free from pain and nervousness. 

Before leaving the subject of hysteric motor ataxy, 
I wish to add yet a single illustrative case in order 
to show that ataxy, connected with hemiplegia, may 
affect a single limb. Such cases approach in char- 
acter the choreoid troubles which accompany or 
follow certain cases of hemiplegia from organic dis- 
ease of the brain, and afford yet another of the 
shadowy resemblances which link the various forms 
of hysterical disorders to their analogues of more 
definite parentage. Miss C, set. 30, grew up in 
luxury and ease, subject to what she somewhat in- 
definitely described as spells of prostration with 



HYSTERICAL MOTOR ATAXIA. 49 

nervousness. At the age of twenty, a sudden death 
in her family caused a sharp convulsive attack, fol- 
lowed by a brief period of insanity, lasting in all 
three weeks. Three years later, her family fell into 
almost absolute want, and she began to work hard 
in the effort at self-support, and then gradually failed 
in health, suffering at intervals from a variety of 
hysterical symptoms. These resulted abruptly in 
incomplete left hemi-ansesthesia, with great loss of 
power in the leg, and lessened power in the hand 
and arm. 

With this report of her case, she came to me some 
months ago. Except a very slight retro-flexion, 
there was no uterine trouble. Neither ovary was 
sensitive, but the spine in all its length, and the left 
side of the chest and the upper part of the belly, 
were very tender — more to touch than deep pressure. 
All other organs were healthy. 

The hemi-ansesthesia as to touch and pain was 
notable in the parts below the waist, and was incom- 
plete in irregular areas, which shifted daily. Pin- 
pricks did not bleed in the leg. 

The hand and arm had good sense of touch every- 
where, but lessened pain-sense chiefly on the radial 
aspect of the arm. The leg was almost motionless. 
The arm and hand could be used with nearly natural 
force, but were stricken with remarkable ataxy of 
movement without the least sign of spasm. The 
utmost concentration of will failed to direct the hand 
so as to enable it to grasp or manipulate an object 
once held. The limb would waver to and fro, and 
at last descend on the object with an effort which 

5 



50 DISEASES OF THE NERVOUS SYSTEM. 

usually carried the hand far to left or right. A 
certain abrupt jerkiness characterized every motion, 
and the failure of directive power was singularly 
illustrated at the piano, where the one incoordinate 
member contrasted with the unusually skilful touch 
of the other. As so often happens in the post- 
paralytic chorea of cerebral lesions, the palsy was 
inversely as the ataxic difficulty, and consisted rather 
in lack of persistent energy than in want of initiatory 
power. 

By slow degrees this ataxy of movement passed 
away, and, what was most curious, it lessened with 
the increase in want of power, while this also has in 
turn disappeared, leaving as yet some dysaesthesia, 
but no notable want of strength. 

There yet remains to us hysteric paresis. Among 
the many disorders w T hich hysteria affords, certain 
ones come clearly out at times from the tangle of 
named or nameless symptoms, and enable us to 
speak of them under some distinct name. It is a 
comfort, amidst so much that is confusing, to find 
these groupings of symptoms ; and, in diseases of 
vague boundaries like neurasthenia and hysteria, a 
good deal of this useful sort of secondary classifica- 
tion is possible. 

The history of hysteria is sometimes one of years, 
and in certain cases, either at the outset or after more 
or less of the strange drama of this disease has been 
played, the patient falls into a state of inertness of 
mind and body, which I am forced, for lack of a 
better name, to call hysteric paresis. 

You might, I presume, feel free to give to these 



HYSTERICAL MOTOR ATAXIA. 51 

cases another label than the one I have given. They 
are, however, over and above all else, pareses — 
examples of intense feebleness, free from any accom- 
panying defect of sensation ; but it is paresis in hys- 
terical women, and if you forget this fact, you may 
be sure that you will have but little success in the 
treatment. 

This disorder may be seen in union with other 
signs which are more or less clearly hysterical; but 
sometimes we find it almost pure from these dis- 
guises, as in the case of Miss L., from New Jersey, 
now in the Infirmary. A person of languid nature, 
not strong in mind or body, she began some years 
ago to be emotional, to have loss of appetite, weak- 
ness, tender spine, vertex headaches, abdominal 
tenderness, and rare convulsions. By and by she 
took to bed, and with more and more complaint of 
her back, and soon of soreness everywhere, ate less 
and less, gave no care to her bowels, and at last be- 
came feeble, sallow, wasted to the limit of wasting, 
and content to lie still most of the time, using mind 
and body as little as she could. From this state I 
rescued her and made her well, and now she is here 
again far w r orse than ever, unable to lift a limb or to 
turn over. She is twenty-two years old, and has not 
menstruated in six months. She is five feet five 
inches, and may weigh about eighty-eight pounds. 
Her skin is rough, dry, unpliant, yellowish, and 
seems to be firmly glued to the bones and muscles 
beneath it. Her morning temperature does not ex- 
ceed 97.5° F. ; her heart beats 90 to 120, and is quick 
and feeble. The other organs seem healthy, and the 



52 DISEASES OF THE NERVOUS SYSTEM. 

secretions normal. She cries at times, but not much. 
Her face, marked with acne, is set, inert, wooden, 
as if she could not smile. The lids droop, the mouth 
hangs a little open, the voice is so feeble that it is 
hard to know what she says. The spine is very 
tender, and to touch it causes a gush of tears; but 
the left iliac fossa and the chest muscles are also 
tender, and compression of any of these hyperses- 
thetic spaces causes nausea and vertigo. Her dislike 
to make any effort was great, but it was also clear 
that the power to move was not lost. There was 
not during movement the jerky action of hystero- 
palsies, but an extreme and evident difficulty in 
motion, and a sudden failure to prolong it; observe 
also that sensation was unimpaired. 

I was very much struck in this case with the ease 
with which these patients become feverish. The 
least overexertion was competent to cause a distinct 
rise in temperature and pulse ; but, for some reason 
not yet clear to me, these changes required some 
hours to produce them. 

All the battery of toning influences was turned on 
this woman, and she is now gaining ground apace. 
She is fed often and in small amount, had for a time 
rectal feeding also — and the mechanical tonics, mas- 
sage and electricity. As usual in all such cases, we 
wait until the flesh is coming back, the color bright- 
ens, and the muscles grow firmer under our mechan- 
ical stimulations, before we call upon her to exert 
herself. Then, in this order, with passive motion — 
motion aided by a nurse, motion resisted by a nurse, 
active motion, unhelped — we shall train her back to 



HYSTERICAL MOTOR ATAXIA. 53 

a state of health. We shall cure her surely, but 
whether or not she will remain well I cannot say. 
It will depend on what kind of influences surround 
her, on what she is when well. 

I have given here a short sketch of a state of 
paresis, in which with some anaemia or without a 
very marked condition of lack of blood all the func- 
tions are enfeebled, and this is most notable in those 
which involve muscular exertion of any kind. If 
there be also any pain, such as that of spinal irrita- 
tion made worse by motion, the patient is even more 
apt to be sluggish, and is not slow to avail herself of 
this and of every excuse to keep as quiet as possible. 
The real and singular want of power, as measured by 
the dynamometer, the difficulty in beginning as well 
as in continuing a motion, seems to set this apart 
from cases of mere neurasthenia, while the general 
wasting and appearance of malnutrition serve yet 
more deeply to mark the distinction. The disorder 
I have described so briefly is one of those which adds 
many recruits to that large class which some one has 
called u bed cases," and which are above all things 
distinguished by their desire to remain at rest. 

I shall elsewhere give in sufficient detail what I 
over and over allude to in these lectures— my views 
as to how best to treat those difficult combinations 
of hysteria with defective nutrition which are often 
too much for the best of us, and to those pages, and 
to what I have written previously in other places, I 
must now refer you. I have some belief in the occa- 
sional value of induction-currents in hystero-palsies, 
but, as to the direct good to be had out of the drugs 

5* 



54 DISEASES OF THE NERVOUS SYSTEM. 

on which men once relied in the treatment of this 
disease, I have said nothing, because, except to con- 
demn, I had nothing to say, and because I believe 
that the numberless remedies for hysteria to be found 
in the books will be swept by another generation into 
the limbo provided for drugs with decayed reputa- 
tions ; but in thus expressing my self I do not mean 
to say that no drugs have an indirect value. What 
you have to do is to rectify with care positive uterine 
troubles, to treat defects of nutrition, to relieve the 
anaemia so apt to exist in hysteria, to see that every 
function is well cared for, and last, not least, to learn 
what need there is to alter the moral surroundings 
of your patient, and then with kind and patient care, 
and an unbending will, to bring about the changes 
she may seem to require. 



MIMICRY OF DISEASE. 



LECTURE III. 

MIMICRY OF DISEASE. 

You will recall the fact that the case I show you 
to-day is one of three which have presented them- 
selves at this clinic within one week. Each of these 
by chance illustrates a different form of disorder, and 
each of the three is a distinct example of one of the 
various groups of causes which evolve a simulation 
of disease. The literature of this subject is widely 
scattered, and consists chiefly of isolated cases to be 
found in the journals. The best essays on the surgi- 
cal aspect of simulated disorders are the admirable 
lectures of Paget, 1 Skey's 2 little volume, and an able 
paper by Dr. Shaffer, 3 of New York, on hysterical dis- 
ease of joints. Except Russell Reynolds V admirable 
paper on diseases due to fixed ideas or emotions, I 
know of no medical essay of much merit on this sub- 
ject. I regret that the able physician I have just named 
has not further treated of these forms of disorder; no 
one was better fitted to do so. It is, in truth, to be de- 
sired that the whole subject should be handled afresh 
by some as competent observer. It would be easy for 

1 Paget, Sir J., Clinical Lectures and Essays. 

2 Skey, E. C., Lectures on Hysteria. 

3 The Hysterical Element in Orthopaedic Surgery. 

4 See Brit. Med. Journ., 1869, pp. 378 and 483. 



56 DISEASES OF THE NERVOUS SYSTEM. 

me to make up for you an interesting history of these 
troubles from the experience of others, but I think 
that I shall be more pleasantly instructive if I deal 
only, or most largely, with cases coming within the 
range of my own knowledge, and especially if I 
make use of some of the curious self-analyses which 
patients who have recovered have placed at my dis- 
posal. Both for what they betray and what they 
conceal these histories are valuable, and especially 
so when they come from women of educated intel- 
ligence. 

The elements out of which these disorders arise 
are deeply human, and exist in all of us in varying 
amount, while many of the determining and con- 
ditioning factors come from accidental, or, at least, 
external agencies. As a rule, the means at work to 
produce mimicked disease are in the books made to 
seem too simple. 

I have not time to do here as I might wish, and to 
go into the full psychology of this subject, and must 
content myself, therefore, with an outline which shall 
mark out for you the chief causes which supply the 
foundations for simulated diseases, and those which 
build on this, and those which strengthen and guard 
the morbid structure. 

First of all comes the hysterical state, fertile parent 
of evil. However produced, it is a fruitful source of 
mimicry of disease, in its every form, from the mild- 
est of dreamed pains up to the most complete and 
carefully devised frauds Its sensitiveness and mo- 
bility, its timidity and emotionalness, its greed of 
attention, of sympathy, and of power in all shapes, 



MIMICRY OF DISEASE. 57 

supply both motive and help, so that while we must 
be careful not to see mimicry in every hysteric symp- 
tom, we must, in people of this temperament, be more 
than usually watchful for this form of trouble, and 
at least reasonably suspicious of every peculiar or 
unusual phenomenon. 

What it is convenient to call the nervous tempera- 
ment, or that state which may be acquired, and which 
I like to describe as general nervousness, is a fertile 
field for simulated maladies, because in it, as in hys- 
teria, the qualities which we all possess are apt to 
take on a morbid development, and to get out of the 
limits of rational control. 

Of the individual share taken by each of these 
causes I shall by and by speak. Before, however, I 
pass on to lesser premises, I would like to digress in 
order to say a few words in explanation of what I 
mean by general nervousness. You will find this 
term used over and over in these lectures, and also 
in the annual statement of diseases treated at the 
Infirmary for diseases of the nervous system. I used 
to try to classify these cases under other heads, but 
came at last to see that there is a state which is best 
labelled thus, and that after eliminating all the cases 
which can be otherwise classed, a small residuum is 
left to which no other name applies. Some of them 
are more or less neurasthenic people, easily tired in 
brain or body; but others without this, or with this 
peculiarity but slightly developed, are merely tremu- 
lous, nervous folks, easily agitated, over-sensitive, 
emotional, and timid. This state falls on man or 
woman or child, and is not hysteria. It is with some 



58 DISEASES OF THE NEEVOUS SYSTEM. 

people a morbid birth-gift, with some an inheritance, 
and in its worst shapes it is made or acquired by 
misuse of alcohol or tobacco, or tea or coffee. 
Naturally you may think that such a state must be 
slowly created, and usually it is; but also it is true 
that a very permanent state of general nervousness 
may be evolved by the accident of a moment, when 
precedent conditions favor it. In a lecture on general 
nervousness in the male, I mentioned examples of 
this kind, and last week we saw at my clinic a case 
in which a moment of intense terror, owing to the 
fall of a house wall, caused in a healthy girl a state 
of general nervousness, alike serious and lasting. 
However acquired, the condition I have outlined 
highly favors the mimicry of disease. 

Another good growing ground for simulation is 
in a mere lowering of the general tone of health 
from anaemia, or any cause whatsoever. You know 
that out of failing health comes, often enough, nerv- 
ousness or hysteria, but even when these states do 
not arise, mere lowering of the standard helps, in 
many susceptible people, to awaken doubts, sus- 
picions, and terrors, which need little hint or help 
from without to enable the victim to construct a 
morbid edifice of non-existent disease. 

If, then, you should ask me whether for the 
creation of mimicked disorders we need the aid of 
lowered health, of hysteria, or of general nervous- 
ness, I should answer that while such states are 
usually the responsible parents, a small proportion 
of examples arise in persons who, being in absolute 
health, owe the troubles in question to their possess- 



MIMICRY OF DISEASE. 59 

ing some natural or inherited combination of physical 
peculiarities, which becomes a competent mischief- 
maker when aided by external accident. The people 
who, from any cause, simulate disease are, I think, 
apt to be naturally distinguished by certain peculiari- 
ties. They are generally over-sensitive, pain hurts 
them more than others, and is a more important 
matter in life. Perhaps they really feel pain more, 
and, at all events, they complain of it more. As a 
rule, they are timid, fearful, and watchful, nursing 
for evil, any chance word incautiously dropped, and, 
therefore, prone to dwell on physicians' opinions, to 
deduce exaggerated possibilities of trouble, and in 
obedience to the least prediction of ill to consent or 
hasten to take extreme precautions. 

Then, again, you are aware that everyone has 
some capacity for mentally influencing or disturbing 
functions of the body which usually are not under 
the control of volition. A few r w 7 ell people have this 
in a marked manner, and in some hysteric or nerv- 
ous states this power becomes enormously increased 
and widened in range. I do not mean that these 
people acquire the power to w r ill intestinal trouble, 
for instance, but that they certainly may gain ability 
somehow to disturb the bowel functions by thinking 
of them. There are many stories in regard to this ; 
but let the average man endeavor by any mental 
process to cause diarrhoea, and he will, I think, find 
it no easy task. It seems incredible that a woman 
can learn to vomit at will ; but this is common; and, 
also, happily she can be taught to suppress this 



60 DISEASES OF THE NERVOUS SYSTEM. 

vomiting by volitional effort when the will is aided 
by a potent motive. 

Books like Dr. Tuke's are full of stories illustrative 
of such facts, and I myself have seen a large number. 
It is clear, then, that we can sometimes acquire such 
control over functions supposed to be outside of 
volitional rule, and that this is made easier in certain 
temperaments and in states of hysteria, feebleness, 
or nervousness. 

The disturbances thus brought about lie usually 
in the heart or vessels, or in the gastro-intestinal 
tract, and are caused or aided by expectant attention 
or dread, or by morbid watchfulness with a knowl- 
edge of symptoms. 

It has been said by Hunter, as quoted by Tuke, 
that, if a number of men surrounding a table on 
w T hich they have placed each a hand, will fix their 
attention on the member, some of them at least will 
soon feel in the part a peculiar sensation. I have 
tried this in vain, and I have also tried without 
result to cause my heart to beat quicker by merely 
attending to its action, yet I am myself of a rather 
nervous temperament. It is curious to find John 
Hunter avowing the ease with which he could in 
this manner create symptoms, and then to find Sir 
James Paget declaring himself utterly unable to pro- 
duce mimicry of disease by any amount of attentive 
effort. The difference among healthy men in this 
respect must, however, be immense. Of this I had 
once a curious illustration. When a very young 
man, five of us made a series of what are called by 
the homceopathists provings of certain medicines, 



MIMICRY OF DISEASE. 61 

each man being ignorant of the drug taken ; three 
of the five had a great variety of symptoms, but the 
other two had none. It is well to add that the 
symptoms corresponded neither among the observers 
nor to those set down in the homoeopathic manuals. 
My friend, Professor Tyson, will recall an amusing 
example of the effects of expectation in a patient of 
ours. The first day he saw her, in order to use 
electricity, she chanced to have at the time, as she 
always had under excitement, a loose stool. This 
took place also at his next visit; and thereafter he 
never made a call at a set time without causing sharp 
purgation. When he came unlooked for, then the 
whole trouble left her. It brought to my mind the 
case of an English physiologist, who happened to 
have diarrhoea when about to give his first lecture. 
The embarrassment and annoyance were great, and 
so impressed him that for a year he never lec- 
tured without having just beforehand a loose stool. 
The sufferer chanced to relate these facts to a well- 
known physician, then a very young man; being 
himself also a biologist, he unluckily felt interest 
enough in this matter to recall it when soon after 
about to appear for the first time before an audience. 
The excitement attendant on a novel situation, with 
a knowledge of how it had affected another, caused 
it to have a like effect on him, and for a long time 
he was always thus annoyed when about to lecture. 
I have given these as illustrations of increase of 
action under mental disturbances and expectation or 
dread. They could readily be multiplied. In the 
two cases named, anxiety caused the repetition of a 

6 



62 DISEASES OF THE NERVOUS SYSTEM. 

flow which was at first accidental, or, at all events, 
not born of emotion alone. In like fashion arise and 
continue certain of the forms of cardiac and vasal 
nervous disturbances. First there is some sudden 
and unusual influence disturbing the circulation ; 
then, upon occurrence of lesser but like causes, a 
similar trouble arises, until a morbid habit is fully 
formed. 

There exists in all of us, feebler in age and more 
potent in childhood, a tendency to automatic and 
unconscious imitation which is the parent of a good 
deal of the mimicry of disease. It may exist in sim- 
ple forms, or be emphasized by love, anxiety, fear, 
or even by disgust. 

I have said it was potent in the young, and it is in 
them responsible for a good many of the peculiarities 
and resemblances usually set down to inheritance ; 
but it is also to be seen at times in their elders. 
Some months ago, I was showing to a physician a 
very singular case of unilateral grimace. As I 
turned from my patient, I noticed that the doctor 
was repeating with his own features the morbid 
action before him. I said, u Do you know that you 
were imitating this lad's grimace ? " "I know now," 
he said, " but I must have done it without conscious 
imitation." Perhaps no better or more illustrative 
example of the natural tendency could be given. 
This was pure automatic imitation. 

The tendency to cough, when forced for a long 
time to listen to a cough, is an instance where ten- 
dency to imitation is made powerful by sympathy or 



MIMICRY OF DISEASE. 63 

aflection. It may account for some, at least, of the 
false whooping-coughs we meet with. 

A more amusing example is one which I have 
seen several times, but which seems to have escaped 
mention in print. It is the occurrence of vomiting 
in the husband of a pregnant woman. The story of 
one of these unlucky sympathizers is worth telling: 

He was rather noted as an unfaithful mate and a 
man of altogether loose ways. After five years of 
marriage, his wife becoming pregnant — an event 
much desired — he seemed to reform, and was very 
much in her society. Her vomiting, which was 
extremely severe, at last affected him in like manner, 
every clay or two, to his utter disgust. Her second 
pregnancy gave rise to a return of his malady. I 
believe that she ceased to be sick with her third 
child — certainly with her fourth — but, so soon as on 
each occasion he became aware of her state, his 
vomiting came on, and lasted for a month or two; 
indeed, I think, in one case much longer. 

The character of his disorder at length became 
known to his friends, and he was so mercilessly 
chaffed that it was at last almost dangerous to men- 
tion the matter. I have seen other cases — his was 
the worst — but I was told of one in ISTew York, last 
week, and the victim was a physician. 

I may have overlooked something in my search 
through the books for mention of these curious facts. 
Prof. Goodell reminds me of what Francis Bacon 
says (Cent. x. Para. 986) : " There is an opinion 
abroad— whether idle or no I cannot say — that loving 
and kind husbands have a sense of their wives breed- 



64 DISEASES OF THE NERVOUS SYSTEM. 

ing child, by some accident in their own bodies." 
Did he mean vomiting, or some more mysterious 
diagnostic warning? In the Lancet there is brief 
mention incidentally of a husband as having been 
sick at stomach during his wife's pregnancy. 

There could be no better examples than these 
somewhat ludicrous instances of the influence of 
automatic imitative tendencies. In the case just 
mentioned, the habit became so strong that emesis 
was reexcited by a mere knowledge of the fact that 
there existed in the woman the state out of which 
previously had grown the original trouble. 

Instances of graver disease evoked in like fashion 
have been given by Reynolds and Anstie, and always 
it is found that fear, or the sight or the remembrance 
of suffering in others, has been an efficient means of 
aiding the imitative tendency. In this manner trou- 
blesome paresis, simulative of palsy seen in a relative, 
has been produced. The condition thus acquired is 
not a true palsy, and does not give us the full roll of 
symptoms seen in the real case ; but it is something 
more than a mere voluntary imitation, because there 
is often a distinct incapacity for movement. The dif- 
ficulty as to the amount of true pain felt in such of 
these cases as mimic that symptom, I shall more than 
once have occasion to speak of; and it follows us 
everywhere in our efforts to appreciate fairly the ex- 
tent of nerve irritation. It must bear to true pain, 
perhaps, some such mysterious relation as the paresis 
of these cases bears to true paralysis. 

I saw last winter a young lady of highly nervous 
and timorous organization, who was long under my 



MIMICEY OF DISEASE. 65 

care, and at length fully recovered. While in bed an 
indiscreet attendant told her of the horrible agony 
she had witnessed in a case of facial neuralgia, which 
began daily about 11 a. m. A day or two later my 
patient began to have pain in the same locality and 
at the same hour every morning. She was one of 
those women in whom you could cause pain any- 
where by pressure on the spine, and a few suggestive 
and directing remarks; and no more was needed 
than the frequent mention of the torment of another, 
and the remembrance that she herself had already 
had what was called ovarian neuralgia. For some 
days she really seemed to have an intense facial pain. 
It wore away after I ceased to pay any attention 
to it. 

There is a state of mind and body, not rare in well- 
developed hysteria, in which there exists a so mon- 
strous development of this strange power to create 
disorder by thinking of it, that even a slight hint, as 
it were, will suffice to evoke a novel symptom. In 
this disease, indeed, we find women, and men too, 
passing into a mental state in which they are really 
much like people in dreams. Their power to reason 
on the phenomena of the senses leaves them, and 
what they conceive to be the case takes the place of 
that which is. These are they who are hurt by light, 
or believe^they are; who cannot bear noise, or think 
they cannot; who feel vibrations as pain; who live 
muffled lives in dark rooms, and believe they cannot 
walk, or even lift a hand, or move the head. Such 
cases are looked upon as simulations of disease by 

6* 



66 DISEASES OF THE NERVOUS SYSTEM. 

some writers, and are, I am sure, prone to pass into 
that evil stage of hysteria. 

This tendency is, of course, to be met with, to some 
extent, in all grave hysteric cases ; but it is also, as I 
have said, the ruling feature of a few. If you cause 
such hysteric women as these to believe that you can 
cure them, you enlist on your side their own troops, 
for as you can create symptoms, so can you also create 
absence of symptoms. There is in all this something 
like the so-called magnetizing of which we used to 
hear and see so much. Under a fixed belief people 
were made unable to move, or could not close the 
eyes, or could not open them, or were made to seem 
to have a pain by touching a point on the body. The 
patients I speak of are all very subject to like delu- 
sions. You put a finger firmly on the spine, and ask 
if the patient have now a pain in the left breast? 
She says no. You repeat. At last she says, "Yes — 
Oh, it hurts me !" Now, is this pure sham, or is it 
not? Does the presence of the set belief create 
pain ? Is it like the pain of dreams, which seems 
real enough while we are in the state of dreaming ? 
I have thought over all this a great deal. When we 
put a finger on the eye unopened for days, and say 
"Now you can open it," and this is done: or when 
we arrest motion by an order, we see a plain phys- 
ical result which must have behind it a ganglionic 
change out of which it grows; and so it seems to me 
that, looking at the pain evoked by ideas or beliefs 
in the light we get from the motor phenomena, so 
evolved, we are hardly wise to stamp these pains as 
non-existent. 



MIMICRY OF DISEASE. 67 

At the same time that I put forward this doubt as 
to the justice of the common view, I am far from 
thinking that the hysteric girl of the class I am now 
discussing suffers as sharply as she seems to do; the 
emotions are no more under control than in a dream, 
and no pains are little, no burdens light. 

I have now in my care Miss C. from Milwaukee. 
When I first saw her she was in bed, which she quit 
but rarely and with difficulty. The room was kept 
dark, and she w T ore blue glasses over the closed eyes, 
and outside of all a bandage. She used cotton in 
her ears, and her nurse and parents crept about in 
list slippers. She had in all ten pillows, large and 
small, as supports around her, and was, as a young 
hysterical girl once told me, " crowded with symp- 
toms." 

The character of this girl had always been that of 
a person thoughtful of and for herself, and not free 
from esteem for her own mental powers, so that she 
had been able and also very willing by degrees to 
rule a meek household with that reckless despotism 
the throne of which is very often the couch of an 
invalid. 

This case seemed to me one in which set beliefs, 
easily gotten and well nursed, had attained a power 
which gave rise to pain and over-sensitiveness and 
more or less inhibited movement. I began to deal 
with it by learning all I could from the girl herself 
to add to what I already knew of her mind, her 
morals, her habits, tastes, friends, education, and 
home life. Then the talk was allowed to settle on 
her eyes, and at last on the uses of light, and the fact 



68 DISEASES OF THE NERVOUS SYSTEM. 

that its excess hurts even the healthy, but does not 
injure them. When at last she grew interested, and 
with herself for a text that was easy, I said, that per- 
haps a woman of strong character might learn to 
bear the light after long disuse of her eyes: that 
such a one could not get well readily in the dark, 
and that although the light would pain her, it most 
surely could not cause disease. I then left her. with 
the idea that she could in a few days conquer her 
rebel eyes, and that it was absurd tor a woman of 
intellect to let one organ disorder the whole body. 
The next day I found her with open eyes and sun- 
light in the room. One by one the ideas on which 
the case was built were thus artfully removed, and 
she is now after but a few days of treatment far on 
the road to health. 

These victories are less easy with older women ; 
but even then the mode of dealing with them is as 
much a question of the basis of character as of any- 
thing else. Sometimes we only need to dispel one 
symptom to overcome all: sometimes the return to 
health and healthy ideas exacts a long and tiresome 
struggle. Sometimes it is safe to assure the patient 
at the outset that she has but to believe and exert 
herself in order to walk. 

In this infirmary I saw. a few years ago. an abrupt 
success obtained in this latter way in a woman, fifteen 
years in bed, who was made able to walk well in 
three weeks, and I could easily add, were it needed, 
the details of many other and less striking cases. 

I had meant to say something here of that form of 
hysteria in which the patient deliberately acts a part 



MIMICRY OF DISEASE. 69 

and with more or less cunning deceives those about 
her. I have seen a goodly number of these cases, but 
among them I have found quite rare the attempt to 
simulate palsy. It is easy enough to learn when a 
woman is pretending to pass calculi or vomit snake- 
bones, but to know if her loss of power be real, or if 
she be suffering from an inhibitory idea or belief is 
more difficult. I may say, however, that purely simu- 
lated palsies in hysterical girls, lack the qualities of 
hystero-palsies, are too complete, and show no loss of 
feeling. The best cases I can recall were in very 
young girls, and were present with much mental dis- 
turbance, and after a long role of hysteric symptoms 
had been played with success. 

One of the cases I lately showed you was a curious 
and most instructive illustration of imitation where 
distress and terror at witnessing disease in a sister 
were the efficient factors. 

Mary C, aged nine, had frequent, sudden, and 
severe attacks of epilepsy. After they had lasted 
two years, the mother brought her to my clinic, and 
with her a lad aged eleven. He was a puny, feeble, 
pallid boy, easily alarmed, and so nervous that he 
could hardly answer my questions. It seemed that 
nearly six months before I saw him, he ran a nail 
into his foot, and, about the time the wound healed, 
had something like a hysterical attack, which seems 
to have impressed him with the idea that he was 
afflicted in the same manner as his sister. Soon 
after this he had what the mother called a spasm, 
whenever the girl was attacked, and still later when 
he heard she had a convulsion, or at times without 



70 DISEASES OF THE NERVOUS SYSTEM. 

this suggestive cause. His attacks began with tremor. 
He was said then to become insensible and to shake 
all over violently. There was no tongue biting, and 
no coma following the attack, and no facial spasm. 
After becoming satisfied of the psychical origin of 
his disorder, I ordered him a cold douche whenever 
attacked, and directed that he should have the hot 
iron applied to his neck if the attacks did not cease 
in a month. At the same time the sister's fits were 
controlled by bromides, so that he ceased to have 
before him the constant incitement to attacks. With- 
out further treatment, the boy's fits, if I may so call 
them, promptly disappeared, not all at once, but by 
degrees, and he is now well. That in this case the 
fits of the boy were imitative is clear enough — that 
without the model before him they would not have 
arisen is plain. 

"We need not ask a cause for simpler forms of imi- 
tation, as seen in normal functional acts, as when the 
micturition of one in a herd of cattle awakens the 
idea among the rest and leads all of them to follow 
the example. The imitative tendency is a useful part 
of our developing powers, but here in cases like that 
of this boy, where there are other children, he alone 
imitates. Does the terror he only as a timid nervous 
lad feels, intensify his imitative faculty, and what 
motive is there for yielding to such a tendency? It 
may be that there is a certain pleasure in giving way 
to instinctive imitative propensities, and moreover 
we must all have observed how some sick children 
enjoy the important role of being ill, of being cod- 
dled and attended to, and this is especially noticeable 



MIMICKY OF DISEASE. 71 

in large families, or in asylums, where usually no 
one child receives in health undue attention. Such 
aids as these there are, no doubt, to cases of mimicry, 
while sometimes the patient's surroundings are to be 
blamed, as fastening the disorder or even as giving 
such information about symptoms as is consciously or 
not applied to the perfecting of them, the actor re- 
ceiving as it were, from a too sympathetic audience, 
hints which enable him the better to sustain his part. 

Some of you saw but lately the case which sug- 
gests these remarks. Here, again, the actor was a 
lad. The following details of his case I owe to his 
physician, Dr. Benjamin Smith, of Falsington, in 
this State : 

0. P., set 9, had at school a slight chill, and in the 
evening thereafter headache and fever; he was well 
next day, but was said to have had headache the day 
following. At this date the doctor found him suffer- 
ing from great tenderness at several points of the 
spinal column. He could not recall having hurt his 
back, but a few days later declared that he then re- 
membered having fallen so as to strike the back, and 
that the pain was severe ; also, that, on the same day, 
he had fallen so as to hurt his head. Both falls were 
said to have taken place on December 25th. 

As soon as the tender spine and headache were 
known to exist, the lad was kept at home and anxi- 
ously cared for, while the pain in the head increased 
and extended at last to the spine. At this elate a 
remarkable dilatation of the pupils was observed, 
and, the pains increasing, he would lie in bed and 
rub his head for relief, or have it rubbed. Mean- 



72 DISEASES OF THE NERVOUS SYSTEM. 

while his pulse was not above 80, and did not rise 
with the presumed increase of pain ; nor did he lose 
appetite. 

About the fourteenth day the headache was said 
to be at its worst, pains arose all over the body, and 
the muscles of the neck began to be complained of 
as sore and stiff*, while nausea and pretty violent 
vomiting added to the alarm w 7 hich his case excited, 
being set down, despite Dr. Smith's opinion, as an 
attack of cerebro- spinal meningitis. At this time, 
after the vomiting ceased, there w r as a sudden cessa- 
tion of all the symptoms; but in a few days more his 
troubles returned, and with dreadful complaint of 
head and backaches, with universal soreness and 
utter inability to walk, he was at last brought to me 
for an opinion and for treatment. His case had then 
lasted five weeks, and was supposed by some phy- 
sicians and by his relatives to be of a dangerous 
gravity. 

When I saw this lad he was lying in bed, some- 
what flushed, but not in a bad condition ; his pulse 
was 85 ; his breathing 20 ; his temperature normal. 
His eyes were bright, and I w T as struck, as Dr. Smith 
had been, by the widely dilated pupil. He was con- 
stantly declaring that his head hurt him ; and it was, 
as I observed, very notably retracted, the muscles of 
the neck being stiff and tender. Any effort to flex 
the head gave rise to tears, remonstrances, and urgent 
cries of pain. The scalp was everywhere tender and 
the whole of the erector spinae muscles w^ere also sore, 
so that the least tap or touch upon them caused him 
to cry. His legs were gathered up close to his body, 



MIMICRY OF DISEASE. 73 

and, besides some loudly expressed annoyance when 
exposed to a bright light, he complained bitterly of 
the vibrations caused by carriages passing or of the 
steps of his nurses when they moved across the room. 

If, however, he were interested in anything, I 
found that I could flex the head or touch the spine 
without causing pain until his attention w^as recalled 
to the act. This — with the absence of fever, the 
calm pulse, the fair appetite, and a certain watchful 
and furtive expression — led me to believe that he 
was more or less consciously mimicking disease. As 
soon as I felt secure in my opinion, I lifted the lad 
out of bed, and, with severity, ordered him to stand 
up ; he hesitated a moment, and then dropped the 
flexed limbs under him, lifted his head at a second 
order, and, as I released him, walked to his bed — a 
feat w r hich he had been supposed to be utterly unable 
to do. After this there w r as no trouble ; he was kept 
out of bed, and, with a rough rubbing daily and a 
little urging, was able to play in the garden in three 
days, and to go home in a week. His pains, stiff 
neck, and tender spine w T ere never heard of after the 
first day in the hospital. I was careful to have him 
kept on a farm away from his home for some months. 
There has been no relapse. 

This case excited great attention, and was the 
centre of the too affectionate regards of many rela- 
tives. The lad became early aware that he was 
believed to be in grave danger. His head and spinal 
pains w r ere attributed to meningitis, and the symp- 
toms discussed in his hearing. Only thus can we 
account for his curious condition, when, in the face 

7 



74 DISEASES OF THE NERVOUS SYSTEM. 

of opposition founded on his presumably serious 
state, Dr. Smith brought him to me. 

I saw, some years ago, a like case in the person of 
a young woman who had nursed two cases of cerebro- 
spinal meningitis. Her imitation was admirable, and 
for some days took in both her own physician and 
myself. 

Careful use of the thermometer, and a rigorous 
study of symptoms, can alone enable us to avoid such 
traps as these. They illustrate what may occur in 
nervous people, under the influence of depressing 
agencies, and when surrounded by too great sym- 
pathy, and by all the information needed to enable 
them to act a part. 

The lessons which such cases teach us are obvious 
enough. The need for care in discussing symptoms 
before nervous women or children, the necessity of 
early apprehension of the true state of things in 
simulated disease, and the wisdom of acting deci- 
sively when once we are sure of our ground, are all 
of them points on which it is hardly needful that I 
should dwell. 

In October, 1880, I was asked by Dr. Stryker to 
see in consultation a number of cases at the Church 
Home for Children, and, as these present the most 
amazing illustration of mimicked disease I have 
ever seen, I shall describe them as being the best 
possible illustration of nearly every point on which 
I have dwelt. The home is a handsome, wholesome 
asylum for children, and is situated a few miles from 
Philadelphia. It contained about 95 girls and but 
6 boys. Both the sick and well, when I saw them, 



MIMICRY OF DISEASE. 75 

were amply nourished, and healthy-looking; nor was 
it possible to find in their home or in their habits any 
influences which could be credited with giving birth 
to neurotic tendencies. The diet was good, the 
hours regular, the play and out-door life sufficient; 
neither was there in the education given, nor in the 
religious training, anything with which it was pos- 
sible to find fault from a medical point of view. 

Dr. Stryker gives me in substance the following 
account: Margaret Trimble, set. 12, a rosy and sturdy 
brunette, in admirable health, is one of a neurotic 
breed, there being in the immediate family two cases 
of infantile palsy. On September 4th, in the dormi- 
tory, when in bed at night, she began to have with- 
out known cause, unless it might have been a trifling 
indigestion, slight convulsive twitches of the arms 
and legs, with a little numbness of the extremities. 
This was a matter of a half hour, and she got up well 
next day. There were no further attacks until the 
11th, and thenceforwards they returned daily. At 
first she was well in the intervals, and slept and went 
about like the other girls. Her respiration during 
the attacks was harsh and noisy, and she made at 
each inspiration a loud crowing noise, much like the 
breathing in croup. The attacks, rare at first, soon 
became frequent, and lasted from fifteen minutes to 
three hours ; attention from others inevitably brought 
them on, even when she was seated and laughing or 
chatting with her companions. She would then slip 
down to the floor, and hands, feet, and body would 
be seized with uncontrollable convulsive motions, so 
that it was impossible to keep upon her person clothes 



76 DISEASES OF THE NERVOUS SYSTEM. 

or bed-covering. During an attack she lay on her 
back, or rolled from side to side, while both arms 
and legs thrashed the floor with quick and hard 
blows. The bodv was lifted from moment to mo- 
ment, and thrown down again with violence, in a 
fashion strange to see. Meanwhile, her face was 
contorted with swiftly changing grimaces, and the 
tongue thrust out and drawn in, while her head was 
thumping hard on the floor. Sleep was apt to fol- 
low a fit; and there was at times, and later in the 
case, a good deal of choreoid difficulty in moving, 
or in handling objects ; at times the crowing existed 
alone, and at times the legs became feeble, and she 
stumbled and fell about. 

This child was sent to the Hospital of the Univer- 
sity of Pennsylvania, where she remained two 
months, under the care of my friend, Professor 
Horatio Wood. Dr. Musser, the Eegistrar, sends 
me his notes, from which I add the following par- 
ticulars : 

The muscles of the face, neck, eye, and tongue 
were at this time unaffected by the spasms. While 
seated she swayed backwards and forwards in clonic 
spasms. When lying down, her spasms were much 
as I have described them. There was lack of co- 
ordination in all arm and hand movements, but no 
anaesthesia anywhere. There was tonic spasm of 
the adductors of the thighs, and in a slight degree 
of the flexors of the forearms. All movement ceased 
in sleep. There was no lesion of the eye-ground. 
The urine was normal. There was a slight systolic 
roughening at the apex of the heart. The usual 



MIMICEY OF DISEASE. 77 

remedies for chorea having failed, the actual cautery 
was twice used on the spine, but with no better for- 
tune. Etherization on a full stomach caused vomit- 
ing for twenty-four hours, and a permanent relief of 
all the symptoms. Under careful and systematic 
training of the muscles, with much urging, and a 
good deal of scolding, she made finally a complete 
recovery. 

This girl's case was seen by many of her comrades, 
and not only excited their amusement and curiosity, 
but led some of them to imitate her " bark," so that 
they were reproved by the matron for their tricks. 

On September 8th, Dr. Stryker being in the home, 
Kate Nichols, a wholesome looking girl of 10, was 
brought to him in the nursery, in what seemed at 
first to be a sharp attack of false croup. She was 
breathing hard, gasping, crowing, speechless, and 
wildly clutching at her throat. Her possible rela- 
tion to the first case was not then understood, and 
she was treated as if for croup. The trouble per- 
sisted all day, and was noted as made worse by noise, 
or any excitement, and to be by and by associated 
with slight convulsive jerkings of the limbs. Mean- 
while, the pulse was rapid, but there was no fever. 
The following night ail of these troubles passed away 
in a sound sleep, from which she awakened crowing 
and barking; and after a day of increasing nervous 
agitation, exploded in a convulsion, identical in 
character with that of case No. 1. The attacks 
thereafter increased in violence, but all of her func- 
tions were well performed. She ate, drank, and 
passed urine and feces as usual; and when free from 

7* 



78 DISEASES OF THE NERVOUS SYSTEM. 

convulsions was merry and pleasant, until the ap- 
proach of a nurse with medicine, or the visit of a 
manager to the Infirmary, started her oft* anew. 
From the outset she began to lose power in the 
limbs. "When held up, she would start fairly, but 
instantly the legs became convulsed, the feet tripped 
one over the other, and she fell in a fit on the floor. 

The girl was also treated at the University Hos- 
pital much as was the last case ; the cautery was of 
little use, but the effect produced by ether on her 
comrade had a decidedly good moral influence, and 
seemed to have a good deal to do with her recovery. 

Case 3. — On September 9th, Sallie Speer was seized 
with the same form of respiratory spasm, but with 
the crowing noise there was a continuous chattering 
of the teeth, like that of a bad ague chill. On the 
10th the usual convulsions came on, she having 
ample preparation from seeing those of the other 
children. In a few days all of her symptoms passed 
away, and she returned to the school-room, for a 
week, when the same disorders reappeared, and she 
was once more placed in the nursery. 

Case 4. — Florence Pierce, set. 12, had about the 
11th like attacks; but, besides the usual convul- 
sions, she had remarkable mydriasis in the intervals. 
While yet able to walk, she had singular attacks of 
festination; and if going towards her bed, would 
run furiously and be thrown headlong across it, and 
on to the floor beyond. Generally she crawled about 
on her hands and knees, with her head swaying 
about as if it was held up with difficulty. 

Case 5. — Miriam Drinkhouse, set. 11, was depressed 



MIMICRY OF DISEASE. 79 

on account of having been placed in a lower class 
than her comrades, owing to her inability to keep 
up w T ith them in their studies. Next day she was 
unable to stand, and her first fit followed on October 
13th. 

Case 6.— Fannie Clark, set. 12, was taken ill with 
respiratory spasms, and the same convulsions about 
October 13th. She had, also, remarkable coldness of 
feet and hands, which was not observed in the others. 

Florence Mack, set. 8, Sarah ISTolen, set. 12, Florence 
Mulligan, set. 10, Bella Burk, set. 11, Mary Mitchell, 
set. 12, were all taken about the 12th to the 15th of 
October. Their symptoms were much the same as 
those above described. There w r ere also a number 
of other cases, some slight and some severe. Owing 
to want of space, all the first cases w r ere placed in the 
two adjoining rooms of the infirmary. Here they 
were seen by one another, and also more or less by 
such girls as were engaged in the housework. Other 
cases were soon added, and at last there were at 
least ten cases in the apartments mentioned. The 
results of this companionship may be easily imag- 
ined. At first the convulsions were irregular as to 
time, but after awhile they took place only in the 
evening, and later still in the morning and the 
evening ; although at any time a visit such as mine, 
or that of Dr. Stryker, or of a lady manager, was 
sufficient to start the attacks. Then one girl would 
begin to bark or twitch, then a second and a third, 
until, on bed or floor, or seated, ten or twelve chil- 
dren were wheezing, barking, grunting, crowing, or 
in violent convulsions ; while the bewildered nurses 



80 DISEASES OF THE NERVOUS SYSTEM. 

ran from one to another, presenting a scene quite 
astonishing to witness. 

During a few days there were many interesting 
variations in this singular malady. On one occasion, 
all of the children in the sick ward got out of bed at 
night, and took to walking about on their hands and 
knees; at other times, some of them, speaking in 
their sleep, described their visions. One saw black 
men; another, whose mother had been recently 
pregnant, spoke of herself as having had a child, 
and mentioned the luxuries she considered desirable 
for a person so situated. More commonly the girls 
were scared, or said they were, by wild beasts ; and 
one child would adopt the vision which another re- 
lated within her hearing. After consultation, all of 
the cases were scattered about among different hos- 
pitals, 1 where, as a rule, they made prompt recoveries 
under somewhat various treatments. The cases 
lasted from one month to three. 

1 The Jefferson College, the Presbyterian, and the Episcopal 
Hospitals. I am indebted to Dr. Starr for full notes of several of 

the cases. 



MIMICRY OF DISEASE. 81 



LECTURE IV. 

MIMICRY OF DISEASE. 

The cases with which I have illustrated this sub- 
ject of mimicry of disease have been, so far, some- 
what simple and uncomplicated; nor could they have 
readily or long deceived any watchful physician who 
had had any experience of neurotic maladies. There 
are, however, more complicated cases to be met with, 
and some of these are remote from those so far de- 
scribed, in that the symptoms were not imitated from 
models ready at hand, or wholly learned from gab- 
bling nurses or relatives. 

They exhibit also the curious progress from simu- 
lation, not consciously imitative, to conscious unre- 
sisted simulation, and at last dissimulation. I shall 
relate here two admirable instances of these inter- 
esting combinations of mimicry passing into well- 
sustained fraud. 

A good many years ago I saw, one evening, a girl, 
aged 13 years, who had never had any of the mala- 
dies of childhood excepting measles. When her new 
troubles began she was not as yet menstruating, nor 
did she show any notable signs of womanly develop- 
ment. 

In January, 1866, when skating, her right instep 
became chafed severely, and for this she was kept at 



82 DISEASES OF THE NERVOUS SYSTEM. 

rest for two or three weeks, but received very little 
care from her mother, and, in fact, needed but little. 
One day an attack of indigestion ended in vomiting, 
which was very violent, and which brought about 
her all the sympathy her elder relatives could give. 
From this time her appetite failed, and the vomiting 
recurred at intervals. Long after, she told me that 
she could have vomited less, but that everybody w T as 
kind when she was so sick. Here, at least, was a 
distinct failure to resist, and probably a desire to aid, 
in producing sickness of stomach. The vomiting 
grew more frequent in the spring, and after a fort- 
night of fever, which she is said to have had in June, 
1866, all food was thrown up, and the bowels were 
opened only once in ten days, or even less often. 
These conditions persisted through 1866, with little 
change, the child rejecting everything, and growing 
at last sallow, and desperately wasted. The skin 
became sensitive to touch, so that no water could be 
used for fear of causing convulsions, and most of the 
time she was shaken bv violent hiccough. 

The vomiting, at first accidental, was thus at last 
aided and cherished for a purpose, until, as often hap- 
pens, the morbid act became habitual and despotic. 
But in a nervous system such as this child's no such 
habit could persist without giving rise to other symp- 
toms as grave, while these in turn would be nursed 
and developed to win and keep up the sympathy, 
attention, and importance, which are among the un- 
natural moral appetites, of a nature once started upon 
this disastrous road so strewn with multiple disor- 
ders. When such persons get well, their lips are so 



MIMICRY OF DISEASE. 83 

surely sealed by shame and self-disgust, as to make 
it difficult to verify by frank confession the suspicions 
which arose in the minds of bystanders, or to trace 
the fatal steps by which the victim descends, from 
the state in which she welcomes a symptom, to the 
degradation of creating symptoms. My patient, when 
first seen by me, had been abandoned, as in a dying 
state, by two homoeopathic physicians, who had left 
for her use a prescription of rather ample doses of 
morphia. 

The picture which this child presented when first 
I saw her was not readily to be forgotten. She was 
lying on her back, staring upwards, with glassy eyes 
set deep in dark rings, which faded into a sallow 
leathery skin, drawn tense over projecting bones. 
Her mouth was wide open, the jaw dropped, and the 
whole cavity literally lined with thrush (muguet). 1 
The skin of the body was dry, and splotched with 
islets of dusky red, and the bedclothes were kept off 
of the sensitive surface by a shelter of half hoops. 
As I stood and looked at this singular spectacle, ap- 
parently that of a dying child, she groaned at brief 
intervals, and also coughed a good deal, at such times 
expressing pain in her face, but usually lying quite 
still, with a look of merely the most profound melan- 
choly. A careful study enabled me to find no organic 
disease. Her urine was so scanty that she often 
passed but two ounces a day; but this was not albu- 
minous; the belly was very tender to touch, although, 

1 The coating of oidiam albicans was the most remarkable I have 
ever seen. 



84 DISEASES OF THE NERVOUS SYSTEM. 

if I distracted her attention, neither touch nor pres- 
sure caused any sign of pain; attention was needful 
to enable her to feel these pains, but as it may be said 
that attention is for all pain a reinforcing element, 
too much stress must not be laid on this point. I 
noticed, however, that this wretched, wilted, starved 
creature followed my motions with attentive eyes, 
although she never turned her head. 

I asked for milk, and put wdthin her lips a table- 
spoonful, for which she closed her mouth; a moment 
passed, and with a gulp she threw it up. I repeated 
the dose, keeping a finger on the larynx. Again she 
threw up, or seemed to; for, as the larynx did not 
make the usual upward movement which accom- 
panies the act of deglutition, it was clear that she 
had not swallowed at all. I w T atched this neat little 
fraud several times. Usually she swallowed a part 
of each mouthful, and, holding the rest in her mouth, 
suddenly cast it out w 7 ith a very fair imitation of the 
convulsive act of emesis. When quite sure of having 
correctly observed her, I abruptly charged her with 
the deceit. At first she denied in a faint voice, and 
saying she couldn't help it, began to cry. A little 
sternness enable me to get down her a full glass of 
milk. I then cleared the room of all her friends, 
threw 7 away the hoops, and sat down by her side. 
She was evidently conquered and alarmed, which I 
did not wish her to be. I therefore took her hand 
quietly, and told her that she could get well ; that 
milk was needful ; that, if thrown up, it would be 
given again, and that I meant to feed her whether 
she liked it or not. 



MIMICRY OF DISEASE. 85 

The after-care, which owed its success largely to 
the care of Dr. Wm. W. Keen, was arduous enough. 
The belly — and, indeed, the whole skin — was rubbed 
twice a day with sweet oil ; milk was given freely 
and often, and the bowels rid of their packed con- 
tents by the use of frequent enemata. I found the 
spine exquisitely tender, but, as is often the case, this 
was much helped by ice-bags (dry cold). Meanwhile 
the thrush faded under the use of washes of sulphite 
of soda. The patient's head was elevated a little 
day by day, and the diet was increased and varied. 
The bowels proved so obstinate that nothing but 
croton oil moved them, and the trouble of swallow- 
ing persisted for some time, although lessened when- 
ever her attention could be called away from the act of 
deglutition. Incessant attention to the muscular ap- 
paratus of the throat had made the use of these parts 
difficult, and swallowing having ceased to be auto- 
matic, was reembarrassed by every new concentra- 
tion upon it of an act of will. When she received 
milk in her mouth it always rested there for some 
time; if, however, the head was thrown back, and at 
the same time the larynx pushed up by a hand, this 
sort of hint usually proved successful, and the move- 
ment of deglutition was completed. By degrees this 
trouble passed away, and she gained in strength so 
as to sit up, and after awhile to stand. 

The use of induction-currents to the disused mus- 
cles was a further help, and, with the gain in power, 
came back easier movements of bowels and bladder, 
and a more wholesome moral tone. Within six 



86 DISEASES OF THE NERVOUS SYSTEM. 

weeks the girl was able to call at my house, and she 
is now, I believe, the healthy mother of a family. 

I could never extract from this child, when well, 
anything beyond the statement that she "just could 
not help it;" and if I pressed her further, she said 
she was sorry, and took refuge in tears. 

About two years ago I saw, with Dr. Finn, a case 
quite as remarkable. The girl, aged thirteen years, 
living in Ohio, after an attack of ague, began to limp 
a little one day, and said she had a pain in the right 
knee. A physician examined it, and told her parents 
quite truly that there was no cause for alarm, ad- 
vising at the same time exercise, and a let-alone 
treatment. This would have answered well, and 
have saved much trouble, had not some one per- 
suaded her mother to ask advice of the travelling 
agent of a surgical institute, who diagnosed hip-joint 
disease, put on a temporary splint, and arranged to 
cure the child at the institute. From this time, when 
the little public opinion about the girl pronounced 
for a grave malady, she grew speedily worse, and 
under the influence of the discussions as to the hip- 
joint disease and its symptoms, she began to act out 
as fully as possible the pathological drama so fool- 
ishly taught her. The pain increased, and the leg 
contracted at the knee and hip. At the institute 
things grew worse, and very soon there was double 
hip disease, and local applications, and splints, many 
and wonderful. But when one of these curious cases 
is well engaged in this career of simulation, there 
comes a time when, either because the first trouble 
no longer excites sympathy, or for more complex 



MIMICRY OF DISEASE. 87 

reasons, these forms of disease become progressive 
and invasive. In our little patient, the contractions 
of the thigh remaining, the arms, especially the left, 
became flexed, the feet being in full extension. At 
this time hysterical spasms came on ; the eyelids 
closed, and remained shut; and, most strange of all, 
she was unable to eat before 9 o'clock p. m. In this 
state the child was first seen by Dr. Finn, who re- 
moved her to quiet lodgings, where soon afterwards 
I saw her, and heard this exasperating history of 
folly and quackery. As I first saw her, she lay on the 
bed, her back to the light — -a queer little shrivelled 
creature, tawny of tint, and the skin covered with 
bran-like scales, washing being a rare ceremony. 
Legs and arms were drawn up so as almost to hide 
the thin, ancient-looking and cunning little visage, 
which seemed so blind with its closed but quivering 
lids, and yet so unnaturally astute in its intentness 
of attention when her own case was mentioned or 
discussed. 

Her right hip was red and swollen, and the thumbs 
of both hands had been so long and tightly con- 
tracted as to have caused the palms to ulcerate, while 
the whole skin was sensitive to such a degree that 
the bedclothes were not allowed to touch her, and 
she uttered a muffled cry of dismay and seeming 
terror at every approach ; her voice was reduced to 
a faint whisper, and she was said to be totally blind. 

The treatment in this case was of easy enough 
application in a child. A single nurse was left in 
charge. The legs were violently straightened and 
their owner invited to set them in order, so as to 



88 DISEASES OF THE NERVOUS SYSTEM. 

avoid in future this abrupt and painful treatment. 
We were told as usual that she never could eat until 
nine p. m., and wonder was expressed that, having 
her eyes shut, she was able to know what o'clock it 
was. The clock on the mantle was an obvious aid, 
and at all events, when set forward two hours, the 
nine o'clock meal was asked for at seven. The gain 
in this case was steady and easy enough. I lost sight 
of the child after she left us to return home, but at 
the time of her departure she was nearly well, and, 
I learn, has entirely recovered. 

I have often thought that, if I could induce older 
patients who had been affected more or less like 
these children to relate to me their histories with 
sufficient frankness, I should obtain a larger insight 
into the motives which prompt them to cultivate or 
to create symptoms. As interesting additions to 
this rare branch of medical autobiography the three 
letters which I subjoin must suffice : 

"The period of my life about which you ask me, 
I can only look back upon with a sort of disgust 
which makes it unpleasant for me to speak about ; 
it is only the hope that some one else may be helped 
by it which makes me willing to speak of it at all. I 
was brought up by an invalid aunt, and I often think 
of what you once said to me, that the women who 
indulge their own nervous systems are those who 
most indulge children. My aunt taught me very 
early to notice and dwell upon any little symptom I 
happened to have, and, when I was fourteen,^ un- 
luckily hurt my knee. For this I was kept in bed 
two weeks, and, when I wanted to get up, I was told 



MIMICRY OF DISEASE. 89 

to keep quiet. Under this enforced rest my appetite 
failed, and I began to have nausea. My first vomit- 
ing created a sensation in the household, which I 
think, as I recall it, I enjoyed as making me im- 
portant. Very soon I got to vomiting every day; 
there was none of the nausea which I had at first, 
and which I have since been familiar with as a part 
of sea-sickness. It gave me no annoyance to cast up 
my food, and was, indeed, rather a relief. From this 
time I was surrounded with sympathy and doctors. 
A few months later my aunt died and I was left in 
charge of an uncle and aunt, and became one of a 
large circle of children, among whom I got very little 
of the care which had before this encompassed me. 
I remember well that I resented the change, and, 
finding that if I took little food I excited alarm, I 
began to yield to the tendency to excite distress and 
anxiety by taking little or no food at times. I sup- 
pose this abstinence gave rise to the neivousness, 
and finally to the spasms which came on at this time, 
at least I can give no further explanation; I only 
know that every new symptom caused new anxiety, 
and that I somehow liked it all. After a while a 
new doctor was called in, and under his rule, which 
was very stern, I got better, and was able to leave 
home and go to the seashore, where, under new in- 
fluences and interests, I lost all my symptoms except 
the vomiting, which seemed to me uncontrollable. 
I lost this only by resolute efforts; in fact, by efforts 
so desperate that often, when food rose in my mouth, 
I swallowed it again. I do not think I should ever 
have so tried if I had not overheard a person in whom 

8* 



90 DISEASES OF THE NERVOUS SYSTEM. 

I had a great interest express himself as having heard 
with disgust of my habit. Then, as you know, I 
learned from you that the habit could be broken; I 
succeeded, as you know, and am married and have 
a little girl, and I can promise you that she at least 
will never be allowed to go through what I have 
done/' 

I presume that this partial self-analysis is as near 
to a full and truthful statement of the motives which 
urge to mimetic fraud as w T e are likely to get. I 
have been told by one woman that she was as irre- 
sponsible as one in a dream; while more usually you 
are told simply " I do not know why I did it; I could 
not have meant to deceive any one." My next ex- 
tract from these confessions is in some sense honest 
enough, and, as I said before, is curious, both as to 
what it reveals and what it hides. The writer is long 
since dead, and I am therefore at liberty to use her 
letter with such precautions as make identification 
impossible. 

I had seen my patient in the morning and received 
this letter in the evening. For several weeks she 
had been under my care with these conditions, a good 
rosy color, fair w 7 eight, and regular functions; but at 
times enormous losses of urine and intense spinal 
irritability, which forbade her to stand or to walk a 
step. For her food she ate a chop at breakfast, and 
no other food the rest of the day. You must not 
understand me to say that I accepted all these state- 
ments, but merely as briefly sketching w T hat seemed 
to be her state. This very pretty invalid was a charm- 
ing and witty,-and most accomplished person, After 



MIMICKY OF DISEASE. 91 

her husband's death, she had taken to her couch, and, 
despite aches and ailments, was in her becoming sick 
outfit the centre of an attractive circle, which gladly 
gathered about the couch, on which she was carried 
from room to room. I hardly know under what 
circumstances she developed the full range of her 
powers. The irritable spine came first, and as one 
doctor after another was consulted other symptoms 
were added to her repertory. 

She had been some little while under my care, 
when I saw two things which confirmed my well- 
grounded suspicions as to the nature of her case ; 
she slept alone, disliking the constant presence of a 
nurse ; but she rarely failed to ring for her attendant 
twice every night. 

The last morning I saw her, I had occasion to look 
at her feet, and noticed that her soles were dotted 
with black marks ; coupling this with the fact that 
she had complained of her wood fire as having 
smoked, I concluded that she had been afoot in the 
night, and that the dark marks came from " blacks" 
on the floor, the result of a defective fire draught. 
A moment later, observing some crumbs on her 
bolster, I asked her to sit up that I might examine 
her spine. As she rose, I threw aside her pillow, 
and saw under it two oranges, several slices of bread, 
and a banana. To my amazement she said cooly , 
" Well, now I am caught; I thought you w T ould do 
it soon or late." My rather sharp remonstrances 
seemed only to amuse her, and that evening I re- 
ceived the letter, a part of which I print. 

" Before this reaches you I shall have made ar- 



92 DISEASES OF THE NERVOUS SYSTEM. 

rangernents to leave. The game I have played on you 
I have played on others, and in my restricted life I 
have found it very amusing. You must not blame 
my maid, as I paid the woman who cleaned the room 
to bring me food. I found that doctors got tired of 
my sore back, and that they ceased to feel interest 
in me, a thing I never did like, so I began to com- 
plain of queer symptoms; and as this often aroused 
new interest, I went on experimenting until I hit on 
the starvation idea, which has done very well. Of 
course I got up at nights, and walked a good deal 
too, but how you knew it I would like to know. As 
to the urine, I used to fill up the vessel with water. 
I hope you will not tell my doctor at home, you 
would take away a good deal that is pleasant, and 
spoil an interesting case, too." 

These are the only cases of this form of moral 
obliquity in which I have ever been able to get a 
free confession. They expose, I fancy, to some ex- 
tent, the motives which underlie the duplicity of 
such women. 

The last of these statements is more recent, and I 
have permission to print it. It is in some ways more 
valuable than the others ; the belief this woman at 
last reached as to the want of foundation for her 
presumed physical disabilities, and her continued 
conviction that the pains were as distinct as any 
pain, must, I think, be received with respect. I am 
sure that she has done her best to analyze her symp- 
toms truthfully. 

She came to me on a couch, or litter, from a 
Western State, a girl of 19, not wasted, and of good 



MIMICRY OF DISEASE. 93 

tints. She was said to be unable to walk, motion 
hurt her ; and her eyes were carefully guarded from 
light by a double bandage. She was kindly but 
firmly treated, and was able in a, few days to bear 
sunlight, and to go downstairs. When once she had 
been made sure that all this could be done without 
death, I allowed her to go forward more slowly, with 
such help from tonics, good diet, etc., as I could give. 
She very often talked to me about the cause for her 
disorder, and out of my inquiries and interest in her 
case came the self-analysis I append. It needs no 
commentary. 

" I suppose, in all cases of nervous affections, one's 
natural temperament and constitution play an im- 
portant part; and, doubtless, with me, a tempera- 
ment rather emotional, sensitive, and occasionally 
morbid, had something to do with making possible 
the state I was in when I went to see Dr. Mitchell, 
in December, 1879. 

" The immediate cause for the headaches, which 
began a year before that time and never left me after 
it, seemed to be a few weeks of mental and social 
strain. I had for two years before that time suffered 
from a weak back, had felt constantly tired, spent 
much of my time on the bed, and taken but little 
exercise. But in the fall of 1878 I felt much better 
and undertook study and class recitation, and became 
much interested in some evening literary and social 
clubs. For a few weeks I went every day to the 
utmost limit of my strength, and was then suddenly 
prostrated with severe headache and excessive weari- 
ness. 



94 DISEASES OF THE NERVOUS SYSTEM. 

" I, of course, tried quiet and rest immediately, 
and after a while grew better, but had a return of 
headache and weariness whenever I tried exerting 
myself much again. There is no question that what 
I lacked then was courage. If some one could have 
told me that there was nothing of consequence the 
matter, I am sure I should have overcome the diffi- 
culty and very soon have gained endurance by exer- 
tion ; but, instead, I became afraid to do things for 
fear of bringing suffering; and, as month after 
month passed, I could do less and less. I cannot 
now understand why I could not have seen — why I 
could not realize that the less I did the less I could 
do; but I was blind, and so was everyone else. I 
thought it was some strange, mysterious disease that 
was taking away my strength. By summer, a few 
minutes' conversation or the walk of a block would 
make the pain in my head agonizing, and every 
sound became unendurable. My eyes, too, shared 
in my good-for-nothing state. 

"In the fall, the pain went into my back and 
limbs, and sent me to bed with the strange infatua- 
tion that I could not move without injury, as I cer- 
tainly could not without pain. I had laid in one 
position with closed eyes for eight weeks, before 
going to Dr. Mitchell, in a state of supposed help- 
lessness. One thing I want to say in extenuation of 
myself, and that is, that the pain was real, not 
fancied. Whatever its cause, or however easily it 
might have been averted, it was genuine suffering 
at the time. I was scarcely ever hysterical, either. 



MIMICRY OF DISEASE. 95 

in the usual sense of the term, for, at least, I realized 
the necessity of self-control. 

" In looking back over that year with the light of 
the present, I can only say that I believe there was 
nothing really the matter with me, only it seemed 
as if there was ; and, because of those sensations, I 
carried on a sort of starvation process, physical and 
mental. Why that process should have brought me 
into such a condition, I must leave with some one 
wiser than I to unriddle." 



96 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE V. 

UNUSUAL FORMS OF SPASMODIC AFFECTIONS IN 
WOMEN. 

You will find, if you come to have much experi- 
ence in the cases of hysterical women, that in some 
instances the disorder arises in general convulsions 
following upon a state of acquired nervous instability, 
and then runs on into a great variety of symptoms 
— palsies, hyperesthesias and anaesthesias and con- 
tractions — to end, at last, in years of bed-ridden 
invalidism, or, much more rarely, in spinal sclerosis. 
A single case will thus give you, in disorderly and 
unexpected succession, every scene of what I have 
ventured elsewhere to call the drama of hysteria. 

At the risk of repeating an old story, I have sought, 
in one of these lessons, to relate some of these his- 
tories, chiefly that I might illustrate afresh the 
termination in sclerosis, and partly to show what 
might be done to rescue certain of what seem to be 
the most hopeless of these exasperating cases. 

Apart from these, however, we see two forms of 
hysterical disorder, in which the primary signs are 
either slight and aborted, or remain so inconspicuous 
as to give but little aid in the early diagnosis. One 
of these is marked by mental derangements, and is 
usually treated as simply a causeless insanity until 



SPASMODIC AFFECTIONS IN WOMEN. 97 

some outbreak of the commoner forms of hysteric 
signs reveals the true condition. I mention it here 
only to complete my rather rude and partial classifi- 
cation. The other is characterized by the extraordi- 
nary variety and strangeness of the convulsive dis- 
orders, which, for years, and from time to time, 
afflict the patient ; all other symptoms being present 
rarely, or in feebly represented forms. I propose to 
relate and discuss for you some of the most unusual 
of these cases. 

In 1871, I was consulted by an intelligent unmar- 
ried lady, Miss L. P., set. 26, from Mississippi, for a 
condition of sj^stem which was probably due to cer- 
tain emotional disturbances following a violent onset 
of cholera morbus. The attack was repeated a few 
days later. The day after, she had intense, burning 
pain between the shoulders and down the whole 
length of the spine. This symptom lasted long, and 
with it, for a month, during which she kept her bed, 
there were brief periods of febrile activity. She is 
said to have had no severe headache, and no uterine 
or urinary symptoms. On first rising she found that 
her legs were feeble, and this paresis was best marked 
on the left side. 

When first seen by me these symptoms remained 
unchanged. The weakness of the left side was com- 
plained of both in the arm and leg, and as affecting 
the eye. She needed a supporting arm when walk- 
ing, but did as well in the darkness as in the light, 
and stood fairly well with shut eyes. The left sole 
was slightly less sensitive than the right. Above 
this there was no dyssesthesia. There was also no 



98 DISEASES OF THE NERVOUS SYSTEM. 

analgesia, and heat and cold were well distinguished. 
There was, at times, a sense of extreme weight on 
the chest. The burning pain in the spine was un- 
equally distributed. It was worse at the 5th and 6th 
dorsal vertebrae, and was increased at night and by 
fatigue. The temporary application of ice made it 
worse, and this increased suffering was felt for some 
time afterwards. Elsewhere she had no fixed suffer- 
ing, but complained of darting neuralgic pains almost 
at any point of the body. There was no womb trouble 
of moment. On the left side there was a large area 
of variable iliac tenderness, not great, and sometimes 
absent. It was less on deep pressure than on slight 
touch. The eye-grounds were normal, but she was 
said to have at times double vision, if very tired. 

This case, as I recall it, puzzled me greatly, and 
was finally treated as of organic cerebro-spinal 
origin ; and this idea was strengthened by the fact 
that at times there was distinct rigidness of the 
erector spinse muscles. She came under my care 
first in the autumn of 1872, and gradually improved. 
The back was several times cauterized early in Jan- 
uary, 1873, and great gain followed. Somewhat later 
a slight and singular tottering of gait was seen ; but, 
on the whole, the progress was good and steady ; so 
that, by the end of January, 1874, she could walk 
with ease a quarter of a mile on level ground. In 
February, 1874, Miss P. made the mistake of leaving 
home, and subjecting herself to what was, for her, 
excessive fatigue and much social excitement. Then, 
as always since, fatigue brought on more or less 
nervousness, and the singular forms of spasms which 



SPASMODIC AFFECTIONS IN WOMEN. 99 

have proved so enduring an annoyance. At the close 
of a day of unusual fatigue, on rising from her chair 
to cross the room, she suddenly staggered back, and 
then rotated violently several times. These fits re- 
turned over and over, and resulted within a week in 
fresh dorsal pain, extreme lassitude, and a curious 
inability to keep her balance. Meanwhile, the rota- 
tions were usually, but not always, to the left. The 
loss of equilibrium was great. On rising she would 
pitch forward, and then sideways, and then turn 
swiftly. The pitching was realty convulsive, and 
not due to lack of balancing power, and there was 
no subjective sense of giddiness. She came to see 
me soon after, and was much worse for the journey. 
During ten days of quiet here the rotatory spasms 
gave place to violent and nearly constant spasmodic 
jerking of the head backwards or forwards, to right 
or to left. As this also departed she had a new 
onset of what she called " twists," and thenceforward 
turned only to the left. These spasms were amazing 
things to see — suddenly, while crossing the room, she 
would rotate furiously to the left, about three to six 
times. The turn was very rapid, and seemed to 
begin with the spine. Then the head followed, and, 
as she said, it seemed hard for the legs to keep up 
with the back. 

At other times an irresistible power seemed to 
drag her up on to her tiptoes, where she would re- 
main a moment, as it were, fixed. At this time she 
could walk, or even run, backwards, but a forward 
movement was beset with difficulties. She would 
be, as it were, hurled forward, and then rotate, or 



100 DISEASES OF THE NERVOUS SYSTEM. 

the effort to move in a forward direction would end 
in a rapid retrogressive stagger, followed by rotation 
to left. There was no vertigo except as a result of 
the spinning. In June she went home, and from 
this period she had a succession of slow r gains with 
sudden relapses. If leading a very quiet life, she 
sometimes passed six months without spasms. 
Worry, fatigue, excitement, were all sure to bring 
them on. At times there w T as no warning, but 
usually pain in the feebler leg, nervousness, and 
irritability were premonitory of an attack. Then 
she would of a sudden find one leg oddly twisted 
around the other, or would be drawn up on to her 
toes, or forced to walk on her heels, or would pitch 
hither and thither, not from weakness, but from 
alternating unilateral spasms. At these times her 
will seemed to be absolutely suspended. "It is," 
she says, " as if some other will-power had me in 
possession. I struggle against it in vain." 1 

The first point to notice in this case is its generic re- 
lation to the class of functional spasms of Duchenne; 
those in which spastic movements are associated with 
or follow some form of normal muscular action. 
Such spasms do not arise during repose, and in this 
sense chorea is at first, and in some cases throughout, 
as I have elsewhere observed, a form of functional 
spasm. 2 Perhaps I shall, in a measure, clear your 
minds as to the nature of what I mean by functional 
spasms if I recall to you the influence of strychnia in 

1 For analogous cases see Russell Reynolds's System of Medicine, 
art. Chorea. 

2 Am. Journ. Med. ScL, October, 1876. 



SPASMODIC AFFECTIONS IN WOMEN. 101 

large doses — such as you have seen given here many 
times. You will remember that in certain spinal 
maladies, such as those of syphilitic birth, it is my 
habit first to give iodides in heavy doses, and then to 
suspend these for a time, and to give strychnia up to 
the limit of physiological endurance, that is to say, 
until I cause an approach to spasms. When, for ex- 
ample, you give hypodermically the one-fifth to the 
one-eighth of a grain daily — the patient will have 
little or no annoyance if you are careful to insist 
that he remain at absolute rest in bed for two hours 
after each injection. If there be any tendency to 
spastic twitchings of the muscles, the will is com- 
petent to control them, unless, and this is the point 
I would make, the patient attempts to exercise. 
Should he do this, the effort results at once in irregu- 
lar movements of an incoordinate character, and in 
slight or more grave spasms of the muscles em- 
ployed. While at rest there is no obvious trouble, 
but voluntary movement occasions spasms, which are 
the offspring of the poison. They are, in a word, 
functional spasms, and would not be seen at all, with 
limited use of strychnia, were it not for the efforts at 
voluntary action. 

The second consideration to which it is worth 
while to call attention was the great variety of the 
forms assumed by Miss L. P.'s attacks, and the tem- 
porary limitation of the disorder to partial groups of 
muscles. These facts alone would, I think, entitle us 
to suspect hysteria as a cause; and, when we learn 
that no attacks ever took place in the street, and that 
pleasant surroundings lessened the likelihood of the 

9* 



102 DISEASES OF THE NERVOUS SYSTEM. 

occurrence of the spasms, while all depressing and 
enfeebling agencies were apt to bring them on, no 
further doubt should exist as to the parentage of the 
disorder. Muscular action perfect in health loses in 
force and in sureness, and in steadiness, as any one 
falls away from the highest standard of physical con- 
dition, and when there is in the ganglia some cause 
tending towards irregularity in any shape, it also is 
apt to rise into gravity just in proportion to the failure 
in physical status. Add to this emotional disturb- 
ances, which in certain natures are prone to express 
themselves in some form of irregular muscular acts, 
and we have all the needed factors for producing such 
convulsions in persons at all capable of evolving 
them. 

I consider that the treatment, which I need not 
here describe, utterly failed. I never succeeded in 
raising my patient's health to such a level as to put 
her above the possibility of these curious attacks. I, 
perhaps, ought rather to say that I never could keep 
her at that level. The least blow to health w T as with 
her a knock-down, and recovery was slow. Prac- 
tically speaking, the woman who habitually has 
hysterical spasms has something wrong with her 
general health. She is ansemic, or has lost general 
tone, and cannot get up, so to speak, or there is that 
remarkable state of easy tire which is called nervous 
exhaustion, but which were often better called nerv- 
ous exhaustibility, and which is, perhaps, due to 
some form of defective nutrition of the nerve cen- 
tres. Always there is some such cause behind the 
spasms. If we can relieve it we cure the convul- 



SPASMODIC AFFECTIONS IN WOMEN. 103 

sions, or rather make the soil fatal to their growth. 
I do not think this is always possible. There are 
some anaemias which resist all treatment. There are 
some mysterious forms of nutritive failure which are 
never made well. 

I have seen recently a case which somewhat re- 
sembles Miss L. P.'s. Miss C, a native of Maryland, 
set. 21, was sent, when 17 years old, to a school in 
which boys and girls were educated together. Just 
before leaving home she had two slight attacks of 
" stiffness " when rising from the sitting posture. 
While at school she never menstruated, although 
previously regular. Next came a light attack of 
diphtheria, and still her general health seems not to 
have been obviously damaged; but the " contrac- 
tions " grew more frequent until at last one day, in 
class, she was unable to speak, owing to trismus 
which came on as she rose to recite. She went 
home after this event, and in a few weeks her men- 
strual flow returned ; nevertheless the spasms con- 
tinued, and this despite a gradual rise in health, and 
a nature free from melancholy, and prone to seek 
and find healthy enjoyment in outdoor life. A fur- 
ther gain followed a residence of some weeks in the 
West, but still the attacks continued ; nor did it 
seem that almost perfect health secured immunity. 

At present, in 1880, this young woman looks in 
admirable condition ; nor is there, on careful study 
of her case, any evidence of organic disease or func- 
tional disorder. While seated she never has any 
symptom of spasm; but many^times in each day, 
when rising from a seated or recumbent posture, she 



104 DISEASES OF THE NERVOUS SYSTEM. 

is seized with attacks which I have now seen her 
exhibit many times. 

On rising she is seized with spasms of the legs, 
neck, face, and arms and hands. These vary end- 
lessly, and are not often exactly alike in any two 
attacks. Usually the phenomena are these, and in 
this order : 

Just as she begins to move, after rising from a 
chair, she has — 

1. A stiffening of the muscles of the legs, and 
chiefly of those of the thighs. This causes a certain 
constraint in her first steps, but does not prevent 
them. 

Having moved a few steps, she has — 

2. A consentaneous spasm of the neck (twist to 
left and downward pull) of the body ; also to left, of 
the- lower part of the face, either to left or right, or 
stiffness from bilateral spasm of face. The left arm 
is sometimes in violent flexion from fingers to shoul- 
der, or the arm is extended and the hand flexed. 
There is the same variety as to the movements of 
the right arm. When I last saw a fit, the right arm 
and hand were thrown out in rigid extension, the 
left being as perfectly in flexion. 

3. No matter what posture was assumed, she was, 
so to speak, fixed in it for perhaps ten to fifteen 
seconds. The spasm came on, and rather slowly 
culminated in some one odd posture, and there and 
then the woman became, as it were, a statue for the 
moments that followed. 

4. These spasms were painless, and disappeared 
in an instant. 



SPASMODIC AFFECTIONS IN WOMEN. 105 

5. They caused no confusion, or vertigo, or any 
other ill feeling, nor any sleepiness. She went on at 
once to do whatever she had meant, such as to walk 
or to dance. 

At times the attacks are frequent, at others rare, 
and absence from home and change of scene and 
climate seem to lessen the number of fits. 

6. These spasms are often, but not always, pre- 
ceded by a condition which is sometimes chronic, 
at others comes only as an immediate warning of 
attack; at all events, its presence is a sure sign that 
the attacks will come on readily and be more than 
commonly hard to prevent. This precedent state 
consists in a slight general tingling which varies in 
amount, and is apt to be accompanied by a sense of 
stiffness in the muscles of the legs. These are rather 
evidences of a chronic and slight condition of spasm 
than of anything which it is worth while to call an 
aura. 

If, on rising, she stands still a moment and pre- 
pares herself to walk by some indescribable mental 
act, which is not a mere resolve, because here the 
will is quite powerless, she can prevent an attack. 
To rise quickly and walk at once, or to turn abruptly 
just after beginning to walk, are apt to cause fits. 

The relationship of such attacks of functional 
spasm as these is as near to chorea as to epilepsy, for 
the state of which she speaks as favoring and pre- 
ceding a fit cannot for reasons already given be 
looked upon as an aura, and we know of no epi- 
lepsies in which the functional and orderly act of a 
muscle or muscles gives rise in some way to the 



106 DISEASES OF THE NERVOUS SYSTEM. 

irregular and disorderly discharge of nerve force 
which constitutes a spasm. But in grave chorea, 
this is precisely what does occur, the forms of spasm 
having of course in that disorder, as in functional 
spasms, differentiating peculiarities. I gave this 
woman bromide of lithium, chiefly to see if the 
bromides would control or lessen the fits. The 
attacks were not lessened by this agent. 

After this failure I was at a loss how to deal with 
the case. There are spasms which are so nearly a 
part of the normal muscle acts or so tied up with 
them as to be as hard to change by medicine as the 
orderly sequence of any common muscular action, 
nor is the task of reform more easy when years of 
repetition have made deep the easy ruts of habit. I 
could only insist that she must live so careful a life 
as never to rise without being on guard. Then also, 
since violent exertion distinctly lessened her ten- 
dency to spasms, I advised an abundance of exercise. 
The results of this advice were good, and the case 
rapidly prospered when she took to hard housework, 
which happened to interest her very greatly. 

The next case which I desire to add to this group 
of spasmodic disorders, is, like the last two, remark- 
able for the great variety of distorting forms assumed 
in turn. Some of you may recall the patient, a poor 
unmarried seamstress, aged forty-three, tall, thin, 
and with a face constantly and deeply flushed; a 
pulse of 90 to 100, and, so far as I could discover, 
no organic disease. When nearing the age of forty 
she began to have retarded menstrual flow, but 
neither then nor when seen by me a year later, was 



SPASMODIC AFFECTIONS IN WOMEN. 107 

there any uterine trouble. In June, 1878, after some 
family annoyances, she had a severe rigor, ending in 
trismus which came on abruptly, and repeated itself 
thereafter with like suddenness, and at inconvenient 
seasons, usually while she was eating. In August it 
was replaced by dysphagia. She acquired, as a 
consequence of this condition, a deadly fear of the 
abortive efforts to swallow, and would chew for 
many minutes before making an attempt at degluti- 
tion. In the autumn this too passed away, and in 
October she first consulted me at my clinic for a 
"lump" on the chest. I was about to refer her to 
one of our surgeons when her remark that it went 
and came interested me, and I carefully examined 
it. To my surprise the growth was in or on the left 
great pectoral above the breast. It was an oval 
flattened swelling with quite abrupt edges. If I 
carried the arm out so as to make the muscle tense, 
in a few minutes the tumor disappeared gradually, 
and I perceived that it was a phantom tumor with 
which I had to deal. I was familiar enough with 
these as seen in or on the belly, but I now saw only 
my second case of this phenomenon in any other 
muscular mass. The " tumor" was hard and dense, 
and the temperature over it was a half degree above 
that of the neighboring parts. Hard rubbing gradu- 
ally dispersed it, but it formed again in a few hours, 
and I may add was always tender. 

I next found to my great interest that all of the 
pectoral on this side was in a state of curious irrita- 
bility, and this you will recognize as only an increase 
of a normal quality. When, for example, I strike a 



108 DISEASES OF THE NERVOUS SYSTEM. 

healthy muscle with a finger-tip, or better, a pointed 
caoutchouc percussion-hammer, such as that which 
we use to test tendon reflexes — two facts are observ- 
able. First, the whole length of the muscular fibre 
struck contracts, or a large part of the whole length. 
Then, as it relaxes, a little hard prominence forms 
in the muscle at the part struck, and remains for a 
few seconds until it gradually disappears. 1 In this 
woman's case, the secondary local contraction was 
larger than is usual, and lasted for at least a half 
hour or more. A few weeks later, she came to the 
hospital to stay, and now the pectoral tumor had 
gone, and the belly presented the usual appearance 
of a phantom tumor. All of its muscles were 
violently contracted, so as to look like a rounded 
growth. It was painfully tender and the percussion 
note was dull. It, however, presented one peculiarity 
I had never seen in any other such case. Several 
times a day the whole contraction passed away, but 
the least handling of the belly brought it all back, 
or this took place without any interference. The 
woman was during all this time in a state of amazing 
nervousness, and was seized with universal tremor 
whenever any one came near to her bed. Her pulse 
rose at times to 130, and the temperature fluctuated 
daily and irregularly from 97° F. to 105° F. We 
got her well enough to walk about and to leave the 

1 I described these phenomena very many years ago in the Trans, 
of the Phila. Acad. Nat. Sci., not then being aware that Weber 
had called attention to them. They are best seen in the pectorals 
of thin people. 



SPASMODIC AFFECTIONS INWOMEN. 109 

hospital, but the abdominal contraction still existed 
or did so after a year had passed away, 

I have seen a similar false tumor in the calf of a 
highly hysterical lady. It was relieved in a week or 
two by the daily use of massage. 

I shall complete this group of cases by a very 
singular one, which I saw last year. M. B., female, 
set. 59, a worn-out school-teacher, always feeble and 
lacking blood, but otherwise well, had a slight sprain 
of the knee, which forced her to remain at rest. 
Very soon she perceived a rhythmical spasm of the 
middle of the muscular masses of the calf of the left 
leg. The muscle gathered into a hard painful swell- 
ing about five inches below the popliteal space. The 
contraction, which was two by three and one-half 
inches in size, was sudden and horribly painful, and 
the region attacked was always sore, but was most 
so during the spasm. This lasted a few seconds, but 
the space affected was at all times hot and a little 
hard. The spasms were singularly regular, about 
twenty-five to thirty a minute, but there were often 
long periods of one to five hours during which no 
spasm existed. She had been treated in various ways 
without relief, but I was finally enabled to help her 
by rest in bed, the use of a splint, and careful feeding 
and iron, but the local trouble was not entirely cured 
until I had used several injections of atropine, which 
were thrown into the muscle, a plan which was, I 
think, first employed by Drs. Morehouse, Keen, and 
myself, in the Hospital for Nervous Diseases during 
our civil war. 

To complete the group of unusual forms of spasm 

10 



110 DISEASES OF THE NERVOUS SYSTEM. 

in women, I shall only add a case or two of hysterical 
athetosis. Since Dr. Hammond first described this 
interesting member of the family of choreoid spasms, 
I have seen two cases in which the athetoic spasms 
were simulated in hysteric women. One of these I 
saw but once, as it did not return to my clinic ; the 
other was a private patient, and was long under ob- 
servation. 

L. C, set. 25, from Canada, a stout, ruddy, unmar- 
ried woman, was probably overworked at puberty in 
acquiring accomplishments which she can no longer 
use. At 14 she had diphtheria, but no sequent palsy. 
The hysterical aspects of her case are represented by 
tendency to tears, by rare hystero-epilepsy, by fits of 
hysteric coma, by great nervousness, distress at loud 
sounds and bright lights, and by general abdominal 
tenderness. Over and above these it is to be re- 
marked that she has a certain general feebleness, not 
at all suggested by her look of health, nor is she ever 
very steady in her motions, and is liable to a fine 
tremor, which subsides only after she has been for 
some time at perfect rest. Also there is a slight but 
distinct and very slow oscillation of her eyes, so that 
this group of symptoms suggests sclerosis. Other- 
wise she is well, and it may suffice to say so without 
going into negative details as to sensation, motion, 
reflexes, and the functions in general. 

Possibly this is an hysterical woman with an or- 
ganic malady, but to which cause shall we refer the 
athetoic spasms, which I shall now describe ? When 
for relief the hands lie closely locked on her lap, 
save for tremor, little movement is to be seen, but 



SPASMODIC AFFECTIONS IN WOMEN. Ill 

when released, and especially during excitement or 
attention to them, both hands, the left being the 
worse, exhibit the most singular motions. The 
fingers extended, or in extension and flexed on the 
palm, move to and fro, coming together or sepa- 
rating, or crossing the line of the thumb. These 
motions are slow, and of a perfectly disorderly char- 
acter, but they never cease except in sleep and during 
efforts at any manual work, when they are always 
replaced by the slight tremulousness already alluded 
to. In Dr. Hammond's case, at least in the one 
given as a type, the movements continued during 
sleep, and also they were powerful, and there was 
some pain in the limbs concerned, but none of this 
applied to my patient. The motions could be easily 
controlled by another's hand, the resistance being 
but slight, while also there was no pain. When, 
however, my patient grew excited or emotional, the 
movements became rapid, and during her menstrual 
periods, which were natural, this was also the case. 
There was no spasm in the feet. The history of 
these movements is that they arose out of a succes- 
sion of hystero-epileptic fits, with intervals of stupor, 
or of stupor with rigidity. At the close of these 
attacks, although she was in other respects well, the 
fingers were noticed to be strangely affected, and 
the disorder thus begun grew slowly worse. 

The only question is as to the origin of these 
spasms. Is it an athetosis proper, or an hysterical 
imitation of athetosis, or merely athetosis grown, as 
one might say, on an hysterical soil, and modified 
by its place of growth ? Despite the fact that the 



112 DISEASES OF THE NERVOUS SYSTEM. 

athetosis arose directly out of hysterical disorder, I 
incline to the latter view, especially as in many par- 
ticulars the case otherwise conforms sufficiently to 
Dr. Hammond's admirable account. I ought to 
add, however, that in cases more clearly and purely 
hysterical, athetoic movements are sometimes met 
with. 

In my second case, that of an unmarried woman, 
Miss J., set. 40, there were slight mental disorder, 
sensory delusions, left hemianesthesia, an hysterical 
temperament, and slight ovarian tenderness (left). 
Rapid relief of the mental trouble was obtained 
under treatment, with slow improvement and final 
cure of the anaesthesia, large gain in flesh and blood, 
and entire recovery from the hysterical symptoms in 
general. During the early months of the case there 
were at intervals attacks of athetoic spasms. Usually 
these came and went without appreciable cause. 
At other times emotion, especially terror from her 
sensory dreams, seemed able to occasion them. Thej^ 
lasted from five minutes to hours, were not violent, 
conformed absolutely to the type cases, were bilate- 
ral, but ceased in sleep, existed only in the hands, 
and several times ceased when Miss JVs attention 
was diverted. 

The character of these motions differed somewhat 
from the utter irregularity of Hammond's disease. 
I should say they differed unless her attention was 
called to them, in which case no semblance of order 
in the spasms could be seen. When unwatched by 
the patient, the motions consisted in constant slight 
to and fro and lateral movements of all the fingers, 



SPASMODIC AFFECTIONS IN WOMEN. 113 

but at brief intervals. A large range of motion 
would affect first the thumb, and then in turn all of 
the fingers in succession from the forefinger to the 
little finger. 

As this woman improved in general condition the 
finger spasms slowly passed away, and have now, I 
believe, been absent for at least a year. Whatever 
doubt there may be as to the hysterical origin of the 
former case, none can exist as to the last one, so that 
we may, I think, rank hysterical athetosis among the 
forms of clonic spasms seen in this peculiar disorder. 



10* 



114 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE VI. 

TREMOR. 

In accordance with the plan I have followed here 
of treating at one time of groups of symptoms, at 
another of single symptoms, I shall ask your atten- 
tion to some of the minor forms of motor disorder 
found among nervous or hysterical women. 

The subjects I shall choose are Tremor, or tremu- 
lousness, and certain Spasms, usually local, which 
are not within the range of hystero-epileptic states, 
but coexist with perfect consciousness. 

You have seen here over and over the tremor of 
tobacco, of alcohol, of lead, of old age, and also the 
forms of tremor which are yet more active, such as 
are met with in shaking palsy and sclerosis. Besides 
being thus an expression of weakness, as in old age, 
or fatigue, or the feebleness of convalescence, or of 
organic disease, or toxic states, tremor is a sign in 
many people of transient emotion, of fear, of excite- 
ment, of anger, or of grief, almost as natural a motor 
expression in some mobile natures as the facial fea- 
ture spasm, laughter or crying, is of uncontrolled 
mirth or grief. Tremor like these, too, is capable, 
under certain circumstances, of passing over the line 
of healthy functional manifestation and becoming a 
symptom of disorder and lack of emotional control. 
Here we are to consider it as a symptom found often 



TREMOR. 115 

among the nervous, a symptom which may be local 
or general, temporary or enduring, and may, in a few 
cases, be so much the most prominent feature of a 
case as almost to constitute a disorder deserving of 
being itself labelled as a disease. 

If the organic tremors, the offspring for the most 
part of coarse textural changes, be clearly spinal, it 
is interesting to ask if the representative tremor of 
hysteria be in like manner of functional spinal birth, 
a question more easy to ask than to answer; but 
seeing tlie volitional control which many nervous 
patients possess, as regards the symptom tremor, it 
seems probable that, in extreme cases, the cerebral 
ganglia lose those inhibitory qualities which are 
usually active in the healthy. That, however, this 
symptom may be of mere emotional origin, or de- 
rived from pathological changes, becomes important 
in diagnosis where it sometimes chances that a spinal 
malady is painted on a background of hysteria, or 
that hysterical additions arise in emotional patients 
to disturb our belief that we have had to do with a 
malady purely organic. These mixtures of symp- 
toms are, as you will readily admit, when you have 
seen many such cases, as bewildering as charades. 
Some of you may recall the case of Miss M., aged 25, 
a fat and ruddy person, who suffered first from over- 
study, combined with some mental worry. At the 
age of fourteen she had diphtheria, but no sequent 
paralysis, and came to me a few years ago, at this 
clinic, a person looking as little like having organic 
disease as any you are apt to see. About three years 
before I saw her she had had an unfortunate love 



116 DISEASES OF THE NERVOUS SYSTEM. 

affair, which had ended in a high degree of general 
nervousness, a form of trouble which we have very 
frequently had occasion to bring before you, and the 
symptoms of which, I trust, are now familiar to you. 
It came on rather abruptly, as these things some- 
times do, resulting in a tendency to tremor, which 
was excited by the slightest emotion, or the least ex- 
citement or worry, and was always worse at the time 
of her periods. We have also intercalated, in her 
case, a brief history of occasional hysterical spasm, 
with spinal and ovarian tenderness. It seems prob- 
able that on top of this came a condition of organic 
disease of the spine, which is not as yet fully de- 
veloped, but which will in all probability end in a 
general sclerosis, of the character which we call 
disseminated. She has now some slight difficulty 
in walking, vague pains through the limbs, some 
numbness of the feet and hands, and slight diffi- 
culty of speech, a certain drawling of her words, 
quite characteristic of the condition in question; she 
has, too, occasional vertigo, and the disk of her left 
eye is, I think, suspiciously white, while I lind, upon 
careful examination, that the vision of that eye is not 
nearly so good as on the other side. The peripheral 
appreciation of colors is distinctly impaired, so that 
there seems to be only too much reason to fear that 
the optic nerves are suffering from atrophic change. 
The tremor she has at present may have been origi- 
nally, and probably was, purely hysterical, since it 
came and went, and was more or less within control 
of the will. It has now all the characteristics of a 
tremor from organic cause. She cannot thread a 



TREMOR. 117 

needle at all, or eat easily, or carry a full glass to the 
mouth without violent agitation; while the hands are 
for the most part quiet when at rest. Looking at the 
whole of the peculiarities of this case, it seems to me 
extremely probable that it has passed quietly, and 
without the suspicion of her physician, into a state 
of organic disease of the spine. 

You are, of course, aware that there are two forms 
of tremor in connection with spinal troubles ; I may 
coarsely state their peculiarities as follows : One is 
constant while the limb is at rest, and is lessened by 
motion; and the other is less when the limb is at 
rest, and is made very much worse by voluntary 
motion. The tremor of nervousness, and that which 
is seen in hysteria, may be always constant except in 
sleep, or may come and go irregularly, without ap- 
parent cause, but will always be liable, like some of 
the spinal tremors, to remarkable increase under ex- 
citement or expectation, or the sense of being watched. 
It is usually a tremor of variable extent, so to speak, 
the range of disturbance, w 7 hat I may call the width, 
being greater than that of most organic tremors, at 
least at their beginning, while under the influence of 
emotion, or without known cause, it may pass into a 
condition of local or general convulsions, the range 
of motion increasing like the lengthening oscillations 
of a pendulum. In one respect, however, it distinctly 
differs from the tremors of organic origin, which are 
never notably controllable by the will; whereas, 
in people merely nervous, or hysterically nervous, it 
is nearly always possible greatly to limit, and some- 
times for a time altogether to efface the tremor by a 



118 DISEASES OF THE NERVOUS SYSTEM. 

sturdy effort on the part of the patient. The form 
of tremor of which I am now speaking, may be con- 
fined to one limb, or may be so general, that almost 
every part of the body may be agitated by it, and in 
these latter cases, if the muscles of the face suffer 
also, they are apt to exhibit larger movements, rather 
than the finer tremors which affect the limbs. I re- 
member only too well the case of a lady, from one 
of our neighboring counties, which baffled us com- 
pletely, a year or two ago in this hospital. She was 
a woman, aged 32, thin, not ansemic, in fact, rather 
ruddy. The disease began about four years before 
she came to me, and was a general nervousness and 
neurasthenia, caused by a long spell of nursing two 
of her family through fatal maladies. At the close 
of this effort, which is always one of the greatest 
strains that can be put upon a woman, she broke 
down with hypercesthetic conditions of the senses, 
with tender spine, with great fatigue on the least 
exertion, and with a general failure of her nutritive 
functions. I do not remember when the tremor 
began, which was so marked a feature of her case, 
but I think it was a year from the time of the first 
outbreak of her symptoms. When alone in her 
room, and thinking herself unobserved, she was 
usually quiet, except for a twitching movement of 
the face, but when anybody entered, and especially 
when I myself approached, she was seized at once 
with a universal tremor and with extreme general 
nervousness, so that speech became inhibited, and 
deglutition was palsied for a time. 

For some months, at least, the movements were of 



TREMOR. 119 

this character, and only after a time grew what I may 
call larger. This was also the history of each onset 
of shaking. The motion rose from tremulousness 
through large tremor visible to the eye everywhere, 
into a tremor which had in it a certain character 
of violence, and was varied with occasional slight 
jerks of the limbs, and accompanied with perpetual 
agitation of every muscle of the face, so that she 
presented an appearance not less singular than dis- 
tressing. This may pass as a good case, in fact, as 
a rather remarkable case of general tremor, but you 
will understand that this symptom in less marked 
degree is very often to be found as an expression of 
all nervousness, and even of weakness as in conva- 
lescence or in old age, while but few old hysterical 
cases escape without more or less exhibition of it. 

Localized tremors, I mean such as are absolutely 
confined to one part, are somewhat more rare, nor 
do I remember to have had the opportunity of ex- 
hibiting to you here a single illustration of this class. 
I have now under my care, however, a very interest- 
ing woman, who has in both limbs below the knee a 
condition of tremor, which is about as fair an exam- 
ple of what I mean as anything that I have recently 
seen. In her it was caused by a long strain of nurs- 
ing followed by a disastrous railway accident, in 
which though she herself was not injured, one of her 
parents was killed. It was her general condition 
for which she came to me, and the tremor is to be 
regarded as only one symptom. I was told that 
some time ago, she was the subject of general tremor. 
She seems to have now a condition of mind not very 



120 DISEASES OF THE NERVOUS SYSTEM. 

rare among highly nervous women, and which with- 
out much straining of language I might effectually 
describe as mental tremor. A moment of mental 
indecision seems to trouble her in regard to every- 
thing upon which decision is necessary, she revokes 
her opinion, again decides, and so, but with far more 
uncertainty of mind than is shown in her speech, 
comes at last to a conclusion. Her general condition 
is exasperated by hysterical anorexia, by some dys- 
phagia, and by perpetual and distressing tendencies 
to micturition, and by violent flushing of the face. 
Under the influence of tonics, and careful treatment, 
she utterly failed to improve, but since I have placed 
her alone, in the care of a nurse before unknown to 
her, and steadily fed her every two hours, with also 
the daily use of massage, she has so rapidly im- 
proved, that now there remains very little of these 
conditions excepting the tremor of which I have 
spoken, but not fully described. While her hands 
are perfectly steady her feet are most of the time, or 
were most of the time, in a state of tremor caused 
by incessant minute activity on the part of the flexors 
and extensors of the feet, while there is also a good 
deal of trembling of the leg and thigh. It has less- 
ened from above downwards. However quiet her 
limbs, my visit is sure to set them going. She has 
been taught since she came here to restrain these 
movements by act of will, at first for a minute, and 
now for an hour at a time. Aided by the gain in 
general health, this training of the will has proved 
efficient, and there is at present hardly any tremor 
in the right leg, while that of the left is fast disap- 



TREMOR. 121 

pearing. A well-applied bandage in some way helps 
her, perhaps, as she says, by keeping her so reminded 
of the limb as to be able to dominate it. 

A year has elapsed since I wrote the last sentence, 
and she is now entirely well. 

What else need be said of nervous or hysterical 
trembling has been already spoken of in connection 
with my remarks on the subject of general nervous- 
ness, to which it is so apt to be related. What I most 
desire here is that you should never confuse it, as you 
may easily do, with other tremors, but I must have 
said enough to warn you on that subject. 

Alcoholic tremors can only concern us in their 
diagnostic relationships, and it will suffice if I say, 
that as to this tremulousness, and as to other neural 
symptoms, you should be constantly alive to the rare, 
the very rare possibility that your patient may owe 
some of them to the secret abuse of stimulants. I 
say the rare possibility, because in a long and large 
practice among women of the best social class, and 
the one presumed by some people to be prone to 
this vice, I have seen but five or six cases of alco- 
holic drunkenness. I well recall a sad case which 
was brought to me some hundred miles on a couch, 
on account of a shocking state of universal tremor, 
with attacks of prolonged stupor and rarer hystero- 
epileptic attacks. The woman had been " diagnosed 
at/' as she told me, by many doctors, and took a ma- 
licious pleasure in showing me a number of opinions. 
The tremor was incessant and large, but did not 
become worse for my visit, although it was at times, 
I thought, purposely exaggerated, the patient being 

11 



122 DISEASES OF THE NERVOUS SYSTEM. 

distinctly pleased at the importance of the role she 
was playing. I confess, that I too should have been 
deceived as to this case, had it not been for a practice 
which you will do well to acquire, a practice now 
become with me a deeply confirmed and increas- 
ingly active habit of noticing in a room, not only 
the patient but everything else. Missing a bottle of 
cologne from its usual place, where I was apt to make 
use at times of its contents, I said, " Where is your 
cologne?" " My maid upset it," she answered; "she 
upset it on the table yesterday; she is very awkward, 
and did the same thing last week." My eyes natu- 
rally turned to the table, which was of antique ma- 
hogany, varnished. Now, I had observed that when 
cologne falls on varnish it permanently whitens it, 
but this table was clean of spots. I repeated my 
question, and when the same positive answer came, 
I was suddenly sure that she was drinking cologne, 
and this proved to be the case. We wrung from 
her and her maid a sad tale of the fraud and strata- 
gems by which she had been able to indulge in this 
singular habit undetected for years. 



CHRONIC SPASMS. 123 



LECTURE VII. 

CHRONIC SPASMS. 

Chronic spasms persistent through months, or 
even through years of waking life, are rare enough 
among women, but exceptionally rare among even 
the most nervous men. The only cases I recall in 
these arose from nerve wounds. In my book on 
Injuries to Nerves I quoted but one case, which I had 
myself seen. I saw T others which had suffered from 
violent spasm as an immediate consequence of a ball- 
wound, and where, however, the spasm lasted but 
a few hours ; but was in one case so great that the 
nails of the spastically shut hand cut the palm 
deeply. 

You see, therefore, how uncommon is the condition 
of true chronic spasm, and w T hy, therefore, it pos- 
sesses so much interest. 

The chronic spasms of women with hysteria are, 
perhaps, among the most obstinately unmanageable 
of all the graver symptoms of this disorder. They 
are said at times, by the books, to make sudden re- 
coveries. My own experience as to this is the same 
as in hystero-palsies. I do not see abrupt recoveries 
— why, I cannot say — perhaps because the cases 
which reach me are always old ones, much treated. 
At all events, you must have seen enough here to 



124 DISEASES OF THE NERVOUS SYSTEM. 

know that we earn our triumphs, as a rule, by intel- 
ligent and patient care. 

These chronic spasms may affect almost any part. 
You are apt to see the jaw locked; I have seen it 
kept rigidly open. I have seen the head bent on to 
the breast, and so held for months. The false tumors 
of the belly are local spasms of muscles ; such a case 
I saw last year, with Dr. Sinkler, who must well 
remember how the immense tremulousness told us 
what was the constitutional cause of trouble before 
the woman could uncover her supposed tumor. 

Sometimes you will see these verj^ local contrac- 
tions in a part of other muscles. I once saw two 
large, permanent tumors in the calf of the leg. 
They were merely contractions of muscle, and not 
of the whole, bat of a part, and, like some of the 
abdominal contractions, were very tender. They 
came very near to being removed by a surgeon— 
who, too often, made his diagnosis with the knife. 

I have, however, made mention of some of these 
cases in a former lecture, and need not dwell here 
on this especial form of the trouble in question. 

Permanent spasms, then, may affect almost any 
muscle of the body, and be so violent and lasting as 
to excite our amazement that, through many years, 
in some cases, a few groups of ganglionic cells 
should be competent to evolve such enormous 
amounts of force. I recall from my notes one case, 
which was, I think, a very interesting illustration of 
these affections, and which is also worth mentioning 
to you, on account of the success of the treatment, 
and because of the various therapeutical experiments, 



CHRONIC SPASMS. 125 

for experiments they must largely be in the treat- 
ment of this disease, which were made by others or 
by myself. This young lady, Miss C, from Mary- 
land, was brought to me a few years ago, as some of 
my assistants may remember, with violent spasm of 
all the anterior muscles of the right thigh and leg, 
the foot, however, being extended. The rigidity of 
the limb was something extraordinary — it stood out, 
when erect, at absolutely a right angle to the body, 
and no pressure that I dared to use was competent 
to depress it notably without causing extreme pain, 
and soreness of the stretched muscles. When the 
hand was placed upon the anterior muscles of the 
thigh they could be felt to be in a state of tremor, 
as though not all of the muscular fibres were acting 
at once. Probably, owing to the long-continued 
action of the muscles, the limb was never entirely 
relaxed in sleep, nor during the many months she 
was at the hospital was it ever seen to be in any other 
position than at a right angle, or at an angle of 45° 
with the line of the erect body. A multitude of 
therapeutic experiments ending always in failure, 
and the abandonment of the case, had been made by 
several ph} T sicians; nevertheless, I undertook the 
treatment with a certain amount of hope, such, in 
fact, as I always have, when an hysterical case is 
taken away from, her own home and social sur- 
roundings, and subjected to new and revolutionary 
influences. 

I began the study of her case by placing her seated 
at the foot of the bed propped up with pillows, and 
then suspended from her ankle an increasing amount 

11* 



126 DISEASES OF THE NERVOUS SYSTEM. 

of weight, to learn whether I could by degrees de- 
press the limb, and thus wear out the muscles. I 
have, however, seen her carry a weight of fifty pounds 
for three hours, and she was but a frail girl, without 
the limb falling more than a few inches. Under 
ether the limb relaxed, but there always remained a 
certain amount of rigidity, owing, I presume, to 
what I may call the setting of the too long-contracted 
muscle. 

Long before the ether left her, the spasm returned, 
and, therefore, I was quite sure that it was not one 
of those forms of mimic spasms of which I have pre- 
sented to you some curious examples. I next made 
an effort to wear out the spasm by the use of induc- 
tion-currents, using two batteries, but although I 
employed such a power of the batteries as could not 
readily be sustained by any but an hysterical woman, 
I did not succeed in my efforts, and she remained 
much as before. The use of galvanism to the spine, 
no matter what might be the direction of the cur- 
rent, also failed. She was finally cured by very much 
gentler treatment, which consisted in the use, twice 
a day, of the fullest hypodermic injections of atropia 
she could bear thrown directly into the rigid muscles. 
As soon as the atropia began to show its power in a 
certain amount of relaxation of the limb, I also had 
the limb manipulated, having it moved in different 
directions, upwards, downwards, and sideways. 
Under this treatment she steadily improved, and 
finally left the hospital able to walk on crutches, 
with the limb nearly straight under her, but still 
unable to employ it in walking. By this time she 



CHRONIC SPASMS. 127 

had obtained a certain amount of volitional control 
over its action, and in a few months became entirely 
well. There are cases, however, in which steady 
extension of the flexed limb, or steady flexion of 
the extended limb by apparatus will succeed in 
overcoming this rigidity. Of this I have seen an 
excellent example in the case of Miss W., also 
from Maryland, who came to me with the diagnosis 
of general sclerosis, but who really presented one 
of the most extraordinary illustrations of hysterical 
symptoms which I have met with in years. She 
had at one and the same time some general palsy, 
a profound loss of power of the left leg, anaesthesia, 
and chronic hysterical spasm of the right leg, with 
violent alternate spasms and extensions of the head, 
together with a quite marked amount of mental 
hebetude, somewhat rare in such forms of hysteria. 
To make her case still more difficult, I may add, 
that she was fat and rosy, in perfect condition, men- 
struating with ease and regularity, and apparently 
suffering from no organic trouble whatsoever. I say 
to add to the difficulty, because I always feel more 
hopeful of a case of hysteria when it occurs in the 
person of a woman lean, wasted, and anaemic. You 
have then, of course, the chance when building up 
a constitution, to aid your moral treatment by all of 
the profound alterations which you may bring about 
during the process of fattening, and filling with good 
blood an exhausted system. In her case I succeeded 
in extending the limb by the use of a screw appa- 
ratus, and a stirrup fastened to the extended foot, 
and attached to the apparatus below the knee. Per- 



128 DISEASES OF THE NERVOUS SYSTEM. 

haps the anaesthesia of the limb may have aided me 
in this matter, but, as I have said above, it is not 
often that you succeed by these means, and in using 
them you may expose your patient to a second dis- 
order in the form of general convulsions, or local 
spasms in parts remote from that first affected. 

I saw an example of this in the case of a lady 
whom I went to Massachusetts to see, some years 
ago, and who suffered from atrocious chronic spasm 
of the left arm, so that it was always painfully flexed. 
There was no anaesthesia of the limb, and every 
effort to make it straight gave rise, if persisted in, 
to general convulsions, which finally caused, as you 
may imagine, the total cessation of all efforts in that 
direction. 

The treatment of these forms of spasm must usually 
consist in the treatment of the general condition, and 
of what that is, I have already fully spoken, in speak- 
ing of the general subject of the course of hysteria. 

I said in 1881, when these lectures were first 
printed, that section of tendons in hysterical con- 
tractions of muscles was unadvisable. I have now, 
after two years, to modify this statement. During 
this interval I have thrice seen section of the tendo 
Achillis prove valuable. 

In another instance, where, in despair, I cut 
several tendons, the contractions returned with vio- 
lence ; but in all of these cases the first and interest- 
ing effect was sudden arrest of the spasm. 

The cases which did well were all of them young 
women whom I had succeeded in lifting to a higher 
level of health, and in whom, as a consequence, all 



CHRONIC SPASMS. 129 

the hysterical symptoms had faded away, excepting 
this single obstinate spasm of the calf muscles. 
The relation of one case may suffice: 

Miss L., set. 15, who had passed through many 
forms of hysteria, and at last grown sound enough 
to resume her usual studies, returned after two years, 
remarkably well, with the one exception of a con- 
stant spasm of the calf muscles. "When she left me 
two years before, I had hoped that with improving 
health this last relic of hysteria would pass away. I 
was surprised to find that it was as bad as ever, and 
that she was absolutely without any other hysterical 
symptom. The spasm was most violent and always 
was worse for any effort to flex the foot, or from 
prolonged walking. It certainly seemed that, as 
splints and atropine and all else had failed, we were 
justified in using the knife, yet I could not but fear 
that after section of its tendon the muscle might 
continue in a state of spasm. Dr. Sydney Roberts, 
who shared my doubts, divided the tendon, the patient 
being under ether ; but the retreat of the released 
muscle was not extreme nor spastic, and to my 
pleasure, when the tendon reunited, there was no 
return of spasm, the power of the muscle was normal, 
and I had learned a useful lesson. Certainly in this 
case the tension kept up by the tendon was a condi- 
tion of the existence of spasm. There has been up 
to this time — a year having passed by — no return of 
the trouble, nor of any other hysterical phenomena. 

When, then, you meet with chronic spasm in the 
hysterical, deal first with all. the possible causes of 
the constitutional state; and only when you have 



130 DISEASES OF THE NERVOUS SYSTEM. 

• 

succeeded in relieving this can you hope to see the 
spasms get better by any of the local means I have 
mentioned. 

Spasms such as these, are not often purposely 
mimicked, but occasionally you will meet with an 
illustration in this form of that unconscious simula- 
tion of disease, if I may be allowed such a phrase, 
of which I have already so frequently spoken. In 
this disorder there occasionally arises a chance for 
the success of those abrupt impressions upon a 
patient which so amazes alike the sufferer and her 
friends. I recollect, as an illustration, the example 
of a very charming young girl from Rhode Island. 
When I first saw her she was lying on the bed, with 
her knees drawn up, her feet not extended as is 
usual, but flexed. I was told that when she awoke 
in the morning, they were straight, but were almost 
immediately drawn up into the state in which I saw 
them. After going over her whole system and not 
discovering evidences of organic disease, I finally 
made up my mind that it was a case for one of those 
bold experiments which sometimes succeed when 
more timid action fails. After inducing her mother 
to leave the room, I suddenly straightened one of 
the girl's legs. I met with no difficulty until I had 
partially attained my object, and this proved to me 
with certainty, that it was a willed spasm with which 
we had to deal, and not one controlled by volition. 
I then said to her, " I have straightened one of your 
limbs, straighten the other for me." She said, " I 
cannot, but perhaps you can." I straightened it 
with but little difficulty. I then said, " Sit up on 



CHRONIC SPASMS. 131 

the side of the bed." She replied that she had not 
sat up for years, but I finally got her seated with 
much trouble, and then, picking up a gay cravat, 
and tying it around her neck, I said, laughing, " Now 
you are all dressed for a walk, how amusing it would 
be to meet your mother at the door." To my sur- 
prise she yielded, seeming to enter into the fun of 
the idea, and with a staggering gait (such as you 
would expect from one long confined to bed) she 
advanced with me to the door, where she met her 
astonished parent who was just coming into the 
room. She never went back to bed again perma- 
nently, and in a few weeks afterwards was able to 
ride on horseback. 

You now and then meet with cases in which the 
whole range of hysterical phenomena leap into mis- 
chievous life owing to some most trivial wound or 
other hurt, but it also chances at times that a real 
and grave injury of a nerve may give you an almost 
indistinguishable mixture of nutritive and other dis- 
orders the usual result of nerve wounds, and also of 
hysteric symptoms such as may perfectly well arise 
without traumatic cause. It becomes then almost 
impossible to say of a given symptom, such as 
chronic spasm, which may be the child of either 
parent, whether it be hysteric or due to the nerve 
lesion, and yet as concerns treatment, it may be of 
the utmost moment to reach such a decision. The 
following case is a remarkable illustration of my 
meaning. 

I saw last year, with Dr. Morton, P. L., aet. 26, a 
maid-servant, who had, a year ago, a fall in which 



132 DISEASES OF THE NERVOUS SYSTEM. 

she bruised her left side. Being of a nervous and 
impressible nature, it was not surprising that she 
was seized at once with left unilateral numbness 
and slight loss of power. These symptoms faded 
away in a few days as one of the minor injuries due 
to her fall rose into mischievous prominence. In 
falling, she struck her left elbow r so as to cause pain 
down the arm, but not in the ultimate distribution 
of the ulnar nerve. Five days after the accident the 
pain grew worse, and a general hyperesthesia spread 
over the ulnar side and middle of the arm. At the 
same time the lingers began to flex more and more, 
until at last all the finger-tips and the thumb came 
into contact in the position assumed when with all 
of the fingers we hold some small object. The hand 
w r as held in extreme and constant flexion chiefly by 
spasm of the palmaris longus, the tendon of which 
was rigid and prominent. The least eflbrt at passive 
motion of the parts caused intense pain, and the 
hyperesthesia was so great that a touch on any part 
of the fingers, except the thumb and forefinger, and 
on nearly the whole forearm seemed to occasion the 
utmost distress. 

This case, I confess, somewhat puzzled me. Nerve 
wounds of themselves give rise in either sex to hys- 
terical states, so that, except for my knowledge of 
the previous temperament, this condition was of 
little diagnostic aid. The hyperesthesia was ex- 
treme. It is so in many nerve wounds or contusions, 
but, at least early in the case, it does not pass out 
of the distribution of the nerve presumably affected. 
In this case it did not seem to have any accurate 



CHRONIC SPASMS. 133 

anatomical site, that is, it was partly in the ulnar, 
and irregularly there, and in a portion of the median 
and musculo-spiral territories ; while there was none 
of the tactile loss which inevitably accompanies 
nerve lesions, there being agonizing pain, and yet 
lack of accurate sense of touch. Besides this, in the 
present case, the fingers were cold ; there were no 
joint lesions, nor any causalgia or nutritive changes 
in the skin or nails. When, too, I pressed on an 
indifferent point — such as the olecranon process — 
and led her to believe that I was compressing a 
nerve, she described her increase of pain as terrible. 
Either, then, this was a case of slight nervous lesion 
exasperated by the hysterical temperament, or else 
it was not a nerve hurt of any gravity, and all of 
the symptoms had arisen in consequence of a trivial 
hurt, just as a pin-prick may be the starting-point of 
the most extreme and enduring hysterical phe- 
nomena. It would, I think, be difficult to find a 
better illustration of the difficulties in reaching a 
distinct diagnosis in such cases, and yet a diagnosis 
is here, if in any case, most desirable, because, if the 
case be purely due to contusion of the ulnar nerve, 
the question of operative interference is certain to 
arise should the symptoms continue long. This 
woman was put under the daily use of galvanism to 
the arm and hand. Each application was followed 
by relaxation of the contracted parts and by a lessen- 
ing of the hyperesthesia. When the poles were 
applied without making circuit, the same results 
followed, and I have now not the faintest doubt that 

12 



134 DISEASES OF THE NERVOUS SYSTEM. 

the phenomena were from the beginning to the end 
of purely hysterical parentage. 

There is a form of spasm which is sometimes mis- 
taken for paralysis, and is to be met with, as far as 
I know, only among women; that is to say, in a 
large experience I have never encountered a case 
among men; it is what I might call spasmodic 
ptosis. It is to be distinguished from that violent 
closure of the eye which is found with or without 
some disorder of the fifth nerve, by the fact that it 
is simply a quiet shutting of the lid, and a resistance 
on attempting to lift it up with the fingers, and an 
absolute incapacity for a time to raise it by the will. 
If this were a paralytic feebleness, there would, of 
course, be no difficulty in pushing up the eyelid with 
the finger, but, as I have just stated, this cannot be 
done without the exertion of a good deal of force. 
I fancy that, even among women, this condition is 
rare, as I do not remember seeing more than three 
or four instances. I mention them as curiosities and 
as cases which you may occasionally see. There is 
also a paralytic ptosis which is common among 
women, and which I hope you will not confound 
with the malady with which we are now dealing. 
The last example I have seen of spastic ptosis was in 
the person of a lady, who came from the interior of 
Pennsylvania, and who has since died of cancer of 
the stomach. She was a person easily tired, emo- 
tional, and low-spirited at the same time. She 
suffered also from nasal catarrh, and had, like most 
of these cases, no photophobia. During the winter 
previous to her visit to me she began to have, with- 



CHRONIC SPASMS. 135 

out known cause, a closure of the lids. They would 
remain closed for several hours at a time, and then 
would open with probably as little cause as they 
closed. I saw her twice before I obtained an oppor- 
tunity to see this symptom. She then seemed to be 
unable to raise the eyelid, and I could not lift it 
without a considerable amount of effort. I treated 
her for a long time, and in various ways, and she 
had at different times tried galvanism and electricity 
and many other forms of treatment. Section of the 
supra-orbital nerve had been proposed to her by an 
enterprising surgeon, but she got well apparently 
unaided by physicians, and died, as I have said, four 
years afterwards of malignant disease. Another 
case was in a woman of great intelligence and re- 
markable accomplishments who had, I think, injured 
her brain by excessive devotion to study. She had 
no disease of the eye proper, nor any organic malady, 
nor could I say that she was a notably nervous wo- 
man. She had, however, been from childhood a shy 
person, subject to blush too easily, and at times ex- 
cessively embarrassed by the presence of strangers. 
The trouble of her eyes came on for the first time at 
a watering-place. When going to dinner, and sitting 
down, she observed that a great number of persons 
were looking at her as a last arrival ; she mentioned 
the fact to her husband, and was almost immediately 
attacked by a violent closure of the eye, and was 
obliged to be led in this condition from the table. 
When this had happened once, you may well imagine 
that every repetition of the original cause brought 
back a return of the disorder, until at last it was 



136 DISEASES OF THE NERVOUS SYSTEM. 

quite impossible for her to go to table in the room 
with other people. Yon will see that in this case 
emotion, and, after the establishment of the symp- 
tom, the despotic control of an unpleasant memory 
were competent to create and then to continue this 
grave inconvenience. I succeeded in inducing her, 
however, to make an effort to go to dinner, without 
regard to what happened, and to face the slight 
unpleasantness and the talk which her appearance 
might create. Her courage was finally rewarded by 
a cure, which was perfected, so to speak, by a long 
absence in Europe, and constant exposure to the 
very difficulties which had given rise to her first 
attacks. 



m 



fel 



= 3 



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1876-80 



TABLE H 




1. -Averaqe Melati\ r e Hutnicl i ly 
Z. Average of .Barometer* 

3. Average Temperature* 

4. chiton n t ofJfcuLrv & Snow in inches 

5. Dianrcun of 170 separate attacks of Chorea, 

6. Wearv daily Tlanqe of Thermometer* 



1876 - 80 





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3 iVb. of separate attacks of Chorea. 



1878-80 



TABLE IT 



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1871 to 1880 inclusive. 





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/ Dotteet line the temperature curve . 
Z lila^k Hue Tufa tit He palsy cases. 



CHOREA OF CHILDHOOD. 137 



LECTURE VIII. 

CHOREA OF CHILDHOOD. 

Some years ago I was struck with the rarity of the 
true chorea of childhood among negroes, of whom a 
fair proportion applied for aid at my clinic. In the 
hope of securing more full information as to this 
question, I asked my friend, the late Professor Henry, 
of the Smithsonian Institution, to distribute in the 
Southern States a circular, asking the following 
questions : 

1. As to the frequency of chorea in white children. 

2. As to its relative prevalence in localities. 

3. As to its relative frequency in black children 
of pure breed. 

4. As to its frequency in mulattoes. 

5. As to the season of greatest frequency of attacks. 
This circular was sent, for the most part, to the 

meteorological and other observers, who were cor- 
respondents of the Smithsonian, and through them 
to their friends. It reached thus a very intelligent 
class, and fell into the hands of secretaries of State 
and county medical societies, who were at much 
pains to give me the collective experience of large 
numbers of practitioners. 

Had all, or nearly all, of my circulars been an- 
swered, I could have quite fairly mapped out the 

12* 



138 DISEASES OF THE NERVOUS SYSTEM. 

relative prevalency of chorea as to States. As it 
was, my replies gave me the experience of two hun- 
dred and ten physicians scattered through the towns 
and rural districts of the South and Southwest. The 
information thus obtained is very interesting, and, 
however incomplete it may be, is too curious to be 
laid aside. In the hope, therefore, that it may 
awaken ampler and more exact research, I have 
ventured to analyze it. No one can feel more fully 
than I how much it lacks of being perfect as evi- 
dence, or how largely it is open to criticism on 
account of the fallacies which are apt to pervade 
information thus obtained. 

The points with which I shall deal will be : 

The relation of the chorea of childhood — 

To season and meteorological conditions. 

To climate. 

To locality, town or country. 

To race. 

Forms of chorea. 

Relation to season. — It became clear, many years 
ago, to every one who followed my clinics, that as 
the cold of winter faded away, and the changeful 
weather of March and April prevailed, cases of 
chorea became frequent. This continued to be the 
case until, with the warmer season, the number fell 
away, remaining then at about the same ratio through 
the autumn and winter months. 

These facts were so striking that at my desire Dr. 
Gerhard collated all the available cases from the 
note-books of the Infirmary for Nervous Diseases, in 
order to arrive at an accurate determination of this 



CHOKEA OF CHILDHOOD. 139 

point in the natural history of the disease. Soon 
after, Dr. Mills published a like summary of cases 
from the clinic books of the University of Pennsyl- 
vania ; and within a few days Dr. Morris Lewis has 
kindly brought together all of our own cases which 
have presented themselves since the date of Dr. 
Gerhard's paper, with additions from my private 
note-books. This experience thus covers all classes 
of society. 

Dr. Gerhard found that my clinic and note-books 
of private cases gave for the time of attacks of 
sixty-eight cases of chorea, thirty-nine in the spring 
months, ten in the summer, seven in the autumn, 
and twelve in the winter. This result was suffi- 
ciently striking, but was incomplete, because the 
months of attacks were not indicated. The subject 
seemed to me to promise interest enough to repay a 
more exact study, and for this purpose an effort has 
been made to relate the attack to months instead 
of seasons, and to examine into the conditions of 
weather which are to be found in periods of the 
greatest and least frequency of chorea. For the 
intelligent study here made of this difficult subject 
I am largely indebted to the skilful industry of Dr. 
Morris J. Lewis. 

A few years ago no such study would have been 
possible, but, the resources of the Weather Bureau 
having been put at my disposal, I have found no 
obstacle, save in the changes of the method of nota- 
tion in its tables which have been made from time 
to time. 



140 DISEASES OF THE NEEVOUS SYSTEM, 



EXPLANATION OF TABLE I. 

Line 1. Interpreted by using column of figures to 80; is 
intended to represent the mean relative humidity, i. e., 
the mean per cent., and not the mean actual amount, of 
the moisture which could be held in solution at the mean 
temperature of each month ; the amount representing com- 
plete saturation being indicated as 100 — the mean for the 
month being obtained from the daily mean relative hu- 
midity. 
Line 2. Interpreted by using the column of figures 29.70 to 
30.30 ; is intended to represent the mean barometric read- 
ings for each month. 
Line 3. Interpreted by using the column of figures to 80 ; is 
intended to represent the mean thermometric readings for 
each month. (Fahrenheit scale.) 
Line 4. Interpreted by using the column of figures to 80 ; is 
intended to represent the actual rainfall or melted snoiv in 
inches for each month. 
Line 5. Interpreted by using column of figures to 80 ; is 
intended to represent the months of onset of 170 separate 
attacks of chorea. 
Line 6. Interpreted by using column of figures 10 to 20 ; is 
intended to represent the mean daily range of temperature 
for each month. This is obtained by subtracting the mean 
of the minimum temperatures ? of each month, from the 
mean of the maximum temperatures of the same, and is an 
indication of the variableness of the different months. 



EXPLANATION OF TABLE II. 

This table is merely a mean of the five years 1876-80, and is 
interpreted in the same manner as Table I, 



CHOREA OF CHILDHOOD. 141 



EXPLANATION OE TABLE III. 

Line 1. Is intended to represent the actual number of days on 
which rain or snow fell in the different months of the years 
1876-80. 

Line 2. Is intended to represent the actual number of cloudy 
days during the same period — the cloudy days being de- 
termined by the following rule: " In determining whether 
a day is clear, fair, or cloudy, its character will be deter- 
mined by taking the sum of the entire number of fourths 
of clouds, observed at 7 a. m., 2 p. m., and 9 p. m. A 
clear day will be one in which the sum of observed fourths 
is 3, or less than 3 ; a fair day, one in which the sum is 
from 4 to 8 inclusive; and a cloudy day, one in which the 
sum is from 9 to 12 inclusive." 

Line 3. As in Table II. ; is intended to represent the months of 
onset of 170 separate attacks of chorea. 



EXPLANATION OE TABLE IV. 

Line 1. Is intended to represent the number of storm centres 
passing within 750 miles of Philadelphia during the years 
1878-80. 

Line 2. Is intended to represent the number of storm centres 
passing within 400 miles of Philadelphia (1878-80). 

Line 3. Is intended to represent the months of onset of 87 sepa- 
rate attacks of chorea (1878-80). 



142 DISEASES OF THE NERVOUS SYSTEM. 

Remarks and conclusions, — In drawing conclusions 
from these tables, it must be remembered that, while 
the meteorological portion is complete as far as car- 
ried out, the number of attacks of chorea represented 
is by no means the complete number occurring in 
Philadelphia during the five j^ears under considera- 
tion, but is merely a list of as many separate attacks 
as could be collected, where the month and year of 
onset were known without doubt. 

In glancing at Table II. it is seen that the chorea 
line (5) suddenly rises to a very high point in March, 
this month having 85 attacks, or 20.58 per cent, of 
the whole number ; the line then falls suddenly in 
April, then rises slightly during the summer, to fall 
again and reach its minimum in October, viz. : 6 
attacks, or 3.52 per cent.; after this a very slight 
rise occurs. In comparing this line with the line of 
mean temperature alone (line 3) nothing especial is 
seen, the same temperature in the autumn, as in the 
spring, not being accompanied by an increase of the 
disease; nor is much light thrown on the subject in 
comparing it with either the line of the mean relative 
humidity (line 1), or with that of the mean barometer 
(line 2), except that there appears to be an increase 
of chorea with a fall in the mean relative humidity 
and barometric tracings, and vice versa. This can 
also be seen in Table I., but not as plainly as in 
Table II. 

It has been stated that the disease is most preva- 
lent during moist, cold w r eather; but this assertion 
does not appear to be sustained by Table II., where 
it is seen by comparing the lines 1 and 3 that Janu- 



CHOREA OF CHILDHOOD. 143 

ary, February, and December have a much lower 
mean temperature, and a much higher mean relative 
humidity than March, and yet these months have but 
a small proportion of attacks. 

Nothing of any apparent importance can be 
gleaned by comparing the mean daily range of 
temperature (line 6) with the "chorea line. 

In comparing the amount of rainfall and melted 
snow per month (line 4, Table II.), with the chorea 
line, there appears to be a slight coincidence, the 
lines rising and falling together, except in May and 
June, although the amount of rainfall is not propor- 
tionate to the number of attacks. In looking at 
Table III., it is seen that the line representing the 
actual number of cloudy days (line 2) bears a much 
closer resemblance to the chorea line than does that 
of the actual amount of rain and snow (line 4, 
Table II.). In July and August there appears to be 
a discrepancy between the two, but in other respects 
the resemblance is marked; the maximum attacks 
of chorea, occurring in March, coinciding exactly 
with the greatest number of cloudy days, and the 
minimum, in October, coinciding w T ith the minimum 
number of the latter. The increase in the number 
-of cloudy days in November does not have a propor- 
tionate number of attacks of chorea, although a slight 
rise is perceptible. 

Allowance must be made here for the method of 
computing the cloudy days, as the rule previously 
stated is not without its objections; for by this it 
may rain, or there may be a thunderstorm on a clear 
or fair day. The line representing the number of 



144 DISEASES OF THE NERVOUS SYSTEM. 

days upon which rain or snow fell (line 1, Table III.) 
also resembles, in some respects, the chorea line. 
This point will be referred to further on, after a study 
of Table IV. 

Line 1 of this table represents the number of storm 
centres that have passed within a circle, whose radius 
is 750 miles, drawn round Philadelphia as a centre, 
during 1878-80 inclusive. The two previous years 
were omitted, as the storm records were not avail- 
able. It was originally intended to construct a table 
showing the number of storm centres that passed 
within circles of varying radii; but as it w r as seen 
that the resemblance between the storm and chorea 
lines increased as the circles increased in size until 
the largest with 750 miles radius was reached, it was 
concluded to simplify the table by only tracing the 
lines that represent the number of storm centres 
passing within the circles of 750 and 400 miles radii 
respectively ; the latter line (2, Table IV.) being 
inserted to corroborate the statement just made. 

The reason of the resemblances between some of 
the lines in Tables II. and III. now becomes more 
apparent, as they may be considered as component 
parts of a storm, or as some of the factors of a storm, 
so that a partial resemblance between them might 
reasonably be expected. A conclusion which it seems 
justifiable to draw from the foregoing study is, that 
no single factor of a storm explains satisfactorily the 
rise and fall of the chorea line, but it is where these 
are taken collectively, as in the storm line, that the 
greatest resemblance is seen. 

It is worthy of note here that the chorea line of 



CHOREA OF CHILDHOOD. 145 

Table IV. resembles, in all its important features, the 
chorea line of Table III, although there are 83 fewer 
attacks included in it, so that it is reasonable to sup- 
pose, if a larger number of attacks could be collected, 
the resulting line would resemble those depicted in 
the tables. 

It appears that the area over which a storm has its 
influence is strikingly alike in chorea and in neu- 
ralgia, as proved by my former studies in the case of 
Captain Catlin. 1 

It will be seen with what extreme caution we have 
ventured to draw conclusions from the elaborate 
study here made. It is at all events valuable as a 
step in a good direction. 

The facts which come out here so clearly as to the 
time of choreal attacks and their relation to storm 
states would seem to indicate the further need for a 
yet more refined and careful study of other points. 
It were most desirable in future to set apart the 
cases of chorea from fright and to study alone those 
cases in which rheumatism accompanied or preceded 
this disease, while it would be also most interesting 
to learn how far the curve of acute inflammatory 
rheumatism would compare with that of choreal 
frequency. 

It is, of course, probable that other factors than 
conditions of weather may have a share in multiply- 
ing attacks. One of these is certainly the influence 

1 Am. Journ. Med. Sci., April, 1877. The Relations of Pain to 
Weather; and in the Transactions of the Philadelphia College of 
Physicians, vol. vi., 1883. A more complete study covering eleven 
years. 

13 



146 DISEASES OF THE NERVOUS SYSTEM. 

of mental labor. I know of many cases which get 
well when they cease to study, and relapse at every 
new effort to do school-work. With us the public 
schools have their most important examination in 
June, when promotions are made and class rank de- 
termined. The pressure on the children is often 
considerable, and may have its share in the rise of 
the chorea line in early summer. 

It is interesting, as we pass from this subject, to 
pause a moment in order to contrast with chorea, an- 
other neural malady as regards their meteorological 
factors. 

Some time ago my colleague, Dr. Wharton Sink- 
ler, showed that the paralysis of childhood is most 
common in hot weather. He has now, at my request, 
made out the curves of relative monthly frequency 
of this disease as seen at our clinics since 1872, and 
has added the curve of temperature. (See Table V.) 

The gradual rise to a maximum in August sug- 
gests disastrous preparation by the weather of July, 
our month of greatest heat ; and the minimum 
reached in winter is certainly a fact which no pre- 
vious theory of this disease could have prepared us 
to suspect or anticipate. 

Recurrence of Chorea. — The tendency of chorea to 
recur is mentioned by several authors, and especially 
by See. He speaks in one case of six, and in an- 
other of seven returns ; and, what is most interest- 
ing, he fixes on the autumn as the time of relapses, 
as well as of the initial outbreaks, and thinks that 
each successive attack is apt to be lighter than the 
last, which has certainly not held good in my own 



CHOEEA OF CHILDHOOD. 147 

experience. The French authors who mention any 
time for occurrence or recurrence of this malady all 
follow See^s statement. According to him, the six 
autumn and winter months furnish three-fifths of all 
the choreas. This he attributes to the joint action 
of cold and moisture, which seem to him the most 
important factors, but which, as our tables show, 
does certainly not hold good as regards this country 
and latitude. 

Dr. Gerhard's paper mentioned the facts observed 
in this direction at my clinic, and in my private prac- 
tice. Out of 80 cases, 25 had been attacked before. 
Of the 25 cases, 14 had thus had chorea three times ; 
8 had had it twice ; and 3 had experienced it four 
times. Of the 25, nineteen recurred in the spring. 

My later experience has given me cases of chorea 
which have recurred in a yet more remarkable man- 
ner. One young girl had chorea for four years either 
in March or April; then once in February; and then 
for two years in May. In another case the disease 
broke out in a lad set. twelve, and recurred every 
spring for three years. In a third case, the disease 
began in a girl of seven, and missing one year per- 
sisted until she was thirteen, when it ceased to appear. 
The attacks began usually in March or April. 

I never knew a case to recur thus pertinaciously 
in the autumn, although sometimes, in this latitude, 
vernal attacks get well in summer, and recur in au- 
tumn. The same holds good of winter chorea. If 
cured, there is a positive tendency to break out in 
the spring. 

Dr. Morris J. Lewis's table of my own clinics gives 



148 DISEASES OF THE NERVOUS SYSTEM. 

this result as to repetitions of attacks : 126 cases, 
representing 185 attacks. 

Since I have been well aware of these facts. I have 
been accustomed to warn parents of the tendency of 
chorea to recur, and have always given careful in- 
struction as to the general treatment of the child in 
winter, and have always given arsenic as the spring 
began. I have in this way broken up, in many cases, 
the habit of vernal recurrence of chorea. 

How far such facts hold good of other latitudes 
than this I cannot yet say; but I gather from many 
of the letters of answer I received from our warmer 
States, that the onsets of this disease are probably 
more common in winter than with us. I have no 
accurate numbers wherewith to settle the question. 
It would be very interesting to know what law of 
occurrence and recurrence chorea follows in Great 
Britain. 

Relations of Chorea to Climate. Locality. — After I 
had determined the factor which I have here illus- 
trated, I became somewhat interested in the question 
of climate as related to this disease, and was soon 
struck with the slight information on this subject to 
be found in the books. Von Ziemssen says that 
Hirsch has now authoritatively contradicted Rufz's 
statement of the rarity of this disease in the warm 
zones both in black and white. Its relative fre- 
quency is hard to judge of, because there is little or 
no death-rate, and because cases are sometimes noted 
as deaths from chorea, when they were due to other 
maladies. Hence the only evidence is the statement 
of physicians in active practice. 



CHOEEA OF CHILDHOOD. 149 

If I consider this, I should conclude from the 
answers to my questions, that warmth does not nu- 
merically lessen it, as in fact my tables show. It 
appears to exist in all of the larger cities all over 
our Southern States, and also quite freely in Cuba. 
Dr. Finley, of Havana, and Drs. Landetta and De 
Castro, formerly of that city, report it as common 
enough, especially among girls at the approach of 
puberty. I hear like accounts from Lisbon and from 
the great cities of South America. In a few cases 
Southern physicians write me that it is rare even in 
large towns, but when they add the number of cases 
they have seen, it is usually clear that they have met 
with quite as much of this disease as it is common 
to encounter at the North. The facts already pointed 
out, which show clearly enough that chorea is seen 
most in the spring and early summer, might very 
well prepare us to find least of it in such localities 
as the Bermudas, where the temperatures vary so 
little throughout the year; but as to this I have no 
information. 

There is another factor in the case, and an impor- 
tant one. It comes clearly out in the answers I re- 
ceived. Chorea is a disorder engendered in some 
way by the evil influences which are found wherever 
men live crowded together in masses. It is essen- 
tially a disease of cities. The larger cities, both in 
the north and south, furnish it, as I should judge, in 
much the same proportion. There is less in the 
smaller places, and in country practice, north and 
south, it is an exceptionally rare disease. Physicians 
who have been twenty to forty years in rural prac- 

13* 



150 DISEASES OF THE NERVOUS SYSTEM. 

tice, sometimes cannot recall a case, and yet, as we 
know, rare cases are usually the best remembered. 
Among one hundred letters, were twenty represent- 
ing — and it is no bad way to put it — over three hun- 
dred years of practice by men who have never seen 
a case of chorea. 

I should at least have expected to find, that, in 
highly malarious countries, where, as we know, the 
endemic influence tells severely on the health of all 
ages, this lowering cause would be competent to do 
what some combination of atmospheric causes en- 
ables the spring and summer months to do — awaken 
chorea. There is, however, no evidence to favor the 
view that chorea can have a malarial origin, except 
that here, with us, it arises in spring with as much 
certainty as ague. But there is also some direct 
evidence to show that there may even b,e something 
hostile in malaria to chorea — a point which I make 
with considerable doubt. It would seem, however, 
that, in localities where malarious plains are bounded 
by wholesome hills — as a most excellent observer, Dr. 
Ellis, of Elkton, declared, and some other physicians 
also — the chorea which they met with arose on the 
hills, and not on the plains. To this I should add, 
that, in certain of the most malarious regions of the 
South, chorea is a nearly unknown malady. 

It would naturally follow upon what I have said, 
that the disease itself would be found to increase 
numerically in cities in direct proportion to their 
growth. Of the increase of a rarely mortal disorder 
we can, however, have no just conception, and the 
deaths reported as due to chorea must, as I have 



CHOREA OF CHILDHOOD. 151 

said, be regarded with a certain amount of suspicion, 
and this remark will especially apply to years long 
past when there was far less accuracy of discrimina- 
tion as to the causes of death from neural maladies. 

The slightest study of the vital statistics of our 
own cities will show how just is this criticism. In 
Chicago from 1851 until 1866 there is no report of a 
death by chorea at any age. Then in 1866 there is 
one, a girl of 15 years, and then none to 1869, where 
my statistics fail me. The population had mean- 
while increased from 38,000 to 252,000. 

In Philadelphia, between 1807 and 1881, chorea is 
given as the cause of death in 64 persons, of whom 
38 are said to have been under 20 years, and 26 over 
that period of life. In this list are many over fifty 
and many under two years, so that there were prob- 
ably in these two sets a fair proportion of imperfect 
diagnoses. 

Race. — Although aware of the insufficiency of the 
material on my hands to answer thoroughly this 
question, I have felt unwilling not to use the letters 
which so many gentlemen have been at great pains 
to write me. I have, however, hesitated the more 
because the tentative opinion on this question which 
I reached quite early, has been criticised by very 
able Southern physicians as not in accordance with 
the facts they themselves had observed. 

Let me admit, to begin, that in these letters there 
may be many errors ; that rare cases may be for- 
gotten ; that the negro often fails to call on a doctor 
for even serious maladies; and, granting these 
sources of distrust of my statistics, I do not see how 



152 DISEASES OF THE NERVOUS SYSTEM. 

we can fail to conclude as I have done, not that the 
negro is insusceptible of having chorea, but that in 
the black race it is far more rare than in the white. 

Of 'sixty physicians who replied at length— some 
lived in cities or towns, some in the country — twenty- 
seven speak of chorea as rare in the white ; all of the 
rest give the number, or an approach to the number, 
of white cases they can recall. One has seen an epi- 
demic outbreak of chorea. Of these sixty, forty-nine 
have never seen chorea in the black; the rest who 
write speak of it as rare, or mention having seen 
single cases. I should add that many of the exam- 
ples spoken of were women, but exactly of what ages 
is rarely stated. 

Even this curious correspondence of view does 
not, however, impress me so much as the character 
of the writers of some of the letters and the extent 
of inquiry which they have made. It may be well 
worth while to analyze portions of this evidence. 

Dr. B. De Landetta says, as regards Cuba, and 
two others indorse his opinion : " I have never seen 
chorea in the negro, which is strange, because it is 
rather frequent in Cuba among white girls at puberty, 
and because rheumatism is common in the negro." 
Dr. Ch. Finley, of Havana, thinks chorea rare among 
whites; but, despite his appeal to the Havanese 
Academy of Medicine and the publication of the 
questions in its journal, but one case of chorea in 
the black could be heard of. 

Among the letters are several from physicians who 
had been large owners of slaves, and had also had 
extensive plantation practice. One, Dr. Ashe, of 



CHOKEA OF CHILDHOOD. 153 

Alabama, having seen in all seven white cases, never 
saw a case in the negro. 

Dr. Benj. Lee writes that in a year of service in 
the Hospital of the Home for Colored Children, New 
York, he saw a case of chorea in a mulatto girl aet. 
15 end fatally, but has never seen it in the pure 
black. Dr. Kollock writes me from Cheraw, S. C, 
that he has seen in twenty-five years of large practice 
some twelve cases in the white and two in the negro 
of pure breed. Three physicians write me from 
Louisburg, N". C, that one of them in thirty-six years 
of practice recalls six or seven cases and one death 
in whites. Two others have seen a few white cases, 
and none of the three any black cases. Prof. J. L. 
Cabell recalls but live cases in the white, and has 
seen none in the black. Prof. Bemiss, of New 
Orleans, has seen cases both in white and black, and 
does not feel sure as to this question. Dr. Ellis, of 
Elkton, Md., a most competent observer, has ob- 
tained, by careful inquiry, knowledge of thirty cases 
in the white in ten years, and of two in black or 
colored children. Dr. Michel, Montgomery, Ala., 
writes me that no one of the thirty members of their 
County Society ever saw a case in the pure negro. 
The disease is seen in whites. The secretary of the 
Medical Society of Columbia, S. C, from corre- 
spondence in the State and from the debate on this 
subject in the Society, was unable to discover a case 
of chorea in the negro. 

Dr. Peyre Porcher, having put this question to 
thirteen members of the Charleston, S. C, Medical 
Society, received for answer that the disease is not 
common among whites, and that no one of the num- 



154 DISEASES OF THE NERVOUS SYSTEM. 

ber had seen a case in the negro, and to this, Prof. 
E. Geddings adds testimony to the same effect. Dr. 
Laurance, of Hot Springs, Ark., says chorea is found 
very rarely among negroes, more often among mu- 
lattoes, but is not a common disease where he has 
lived in the South. The general evidence in Vir- 
ginia is very much to this effect, but in Richmond it 
is clearly less infrequent, both in white and black or 
colored, than elsewhere in the State. 

On the other hand, many physicians in Virginia 
state that it is as common in one race as in the other, 
and Dr. Landon Edwards, of Richmond, after a care- 
ful inquiry, reached the conclusion that the negro 
has no immunity. 

It seems to me, however, that as the matter stands, 
the weight of evidence is in favor of the opinion that 
the black is less liable to chorea than is the white. 

Varieties of Chorea. — I pointed out some years ago, 
that there exist at least three groups or species in 
the genus chorea of childhood. The significance of 
the distinctions is not as yet clear to me, but I am 
inclined to think that they may indicate a differ- 
entiation in the anatomical sites of the central dis- 
turbances which give rise to this disorder. As they 
are not yet adopted in the books or confirmed by the 
researches of others, I shall venture here to restate 
briefly my views so as sufficiently to illustrate the 
peculiarities I have seen. 

Group First — The common type; awkwardness 
and incoordination of voluntary movement, followed 
soon or late by automatic or unwilled clonic spasms 
of various parts. 



CHOREA OF CHILDHOOD. 155 

Group Second.— The disease never gets beyond the 
first stage of incoordination. Just as in some scle- 
roses of the cord there is no tremor save during 
volitional acts, so here the irregular motions only 
occur during willed actions. 

Group Third is, I think, the most unusual type, 
but I see occasional cases every spring. In this 
there are constant automatic, irregular, clonic spasms 
usually of the hands, but during volitional acts these 
entirely vanish, and the most complicated acts are 
well performed and without obvious incoordination. 
In other cases voluntary motion merely lessens the 
spasmodic activity, but does not abolish it. It is 
necessary to illustrate only this third group. 

T. C, aet. 14, female, applied at my clinic in May, 
1879. She was a florid, healthy looking descendant 
of healthy people, but had one brother who was epi- 
leptic. In March, 1878, she was attacked rather 
suddenly with clonic spasms of both hands. These 
parts were in incessant movement during the waking 
hours, and until she attempted some acts of volition. 
Then, and during the movement in question, they 
were entirely free from all appearance of incoordina- 
tion. She could write, sew, lift a glass of water, or 
do any other act involving complex motion without 
the least tremor, but in a moment after it was done, 
the fingers would again resume their spasmodic 
activity. 

I have seen a number of these cases. They are 
distinctly choreal, and yield to such treatment as is 
of value in that disease, but they differ plainly enough 
from the ordinary type of chorea. 



156 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE IX. 

HABIT CHOREA. 

I have over and over in my clinics called attention 
to a disorder of childhood which is the source of 
some anxiety and more annoyance both to parents 
and physicians. This trouble I venture here to label 
Habit Chorea, and for reasons which, I think, are 
good and which will appear in full as we consider 
the cases. 

Over and over some anxious mother will ask you 
to notice her child on account of some little trick or 
gesture in which the child indulges. Then you will 
see that it is winking rapidly, or pursing up the 
mouth or drawing it to one side, or, perhaps, that 
the brow is lifted at intervals or a shoulder shrugged, 
or some forward movement of the jaw or head is 
repeated over and over at varying intervals. 

These acts occur usually in children of either sex, 
but I think most often in girls from 7 to 14 years of 
age. In many cases the single grimace or motion is 
repeated for months and then disappears, and, if this 
were all, I should hardly think it worth while to label 
so trivial a disturbance of health ; but in other cases 
the first habit is lost by and by, and another takes its 
place, so that the variety and obstinacy of the habits 
become troublesome and even cause alarm; or, worse 



HABIT CHOREA. 157 

still, the little patient has a large repertory of these 
performances, and will execute a remarkable variety 
in one day. Usually, in such instances, there is some 
one motion which is more violent or more frequent 
than the others. 

If you examine with care the history of these little 
patients, you often find that there has been some fall 
from the plane of health, and you will at once wish 
to know wherein the child's life and work and play 
are not what they should be. Sometimes finding 
nothing to blame, you will recall the fact that, in 
the process of growth, children undergo cyclical 
changes which are not permanent, and which in 
turn may bring or take away tendencies to neurosal 
disorders, so that you must not always expect to be 
able to detect the causes of such disease. 

If you analyze more closely the character of the 
symptoms we are studying, you will find quite 
enough to repay your care. You will observe, first, 
that attention to the child increases the trouble, and 
that any little failure in health has a like influence. 
Then, if you see many such cases, you will observe 
that these children are sometimes irritable or excit- 
able, or exhibit clearly enough a condition of nerv- 
ousness, being more emotional than is normal; 
while, in a few instances, they lapse into well-pro- 
nounced chorea of the ordinary type. In fact, this 
disorder has a certain kinship to the latter affection. 
If you ask an intelligent child, who is thus diseased, 
why it makes the grimaces, or repeats, at intervals, 
some odd movement, you will learn that, while the 
patient is able, in most instances, to restrain itself 

14 



158 DISEASES OF THE NERVOUS SYSTEM. 

and control the exhibition of motor disorder, this 
restraining power becomes increasingly difficult the 
longer such effort lasts, and that a certain malaise 
or discomfort results ; while to give way and let the 
morbid impulse have full sway is attended with a 
sense of comfort and relief. 

Such is, in brief, all that I know about this small 
malady; although you will, perhaps, comprehend it 
better if I relate cases and point out, by illustrations, 
the fact that its treatment should be very much that 
which is needed in full-fledged chorea; another argu- 
ment, if a slight one, in favor of the relationship of 
the two disorders. 

During the present month of November I saw M. 
C. Gr., set, 13, girl. Never a robust child ; at the age 
of six she became, without known cause, nervous, 
restless, and irritable; and was, for awhile, a bad 
and uneasy sleeper. About this time she began to 
have a slight hacking cough, which came and went; 
was made worse by an attack of scarlet fever, and 
still exists at times. It sounded like a cough which 
was forced and voluntary. At nine or ten years, 
the cough almost passed away, and was succeeded 
by a sort of snuffling, during which she made the 
usual grimace, always on the left side, and precisely 
such a movement as accompanies snuffling. "When- 
ever she makes this contortion she pushes her cheek 
up with the left hand. For a long while the cough 
and the snuffling act continued, the one or the other 
being prominent for a time. She was scolded and 
bribed into making great efforts to stop these morbid 
acts, and more or less succeeded. The next summer 



HABIT CHOREA. 159 

she was taken to Saratoga, and the cough and snuffles 
abated, but a new sj^mptom arose. The mouth would 
be opened wide, and as it closed both eyes shut, and 
remained closed for a moment, or else this took place 
without any opening of the mouth. 

When I saw the child, all of these odd movements 
were in full activity, but usually one of the three 
was more frequent than the others. There was at 
this time a good deal of dyspepsia, sluggish appetite, 
and pain in the back low down, probably indicative 
of the coming on of her menstrual flow, the ap- 
proach of which was rendered probable by a rapid 
development of her bust and pelvis. She had had 
no worms, and no organic or functional disturb- 
ances other than those I have mentioned. As she 
is just now, for the first time, under treatment, 
I can say nothing as yet of its success. Careful 
and good diet, light gymnastics, no school, gentle 
aperients, and full doses of arsenic constitute such 
therapeutics as seemed to me reasonable. I ought 
to add, that she does not seem in any degree mor- 
tified at her own peculiarities, and this will be met 
by some effort to make the matter appear to her as 
rather disgraceful, and not to be mentioned — some- 
thing, in fact, to be ashamed of. I shall be much 
surprised if this combination of physical and moral 
treatment fails us. 

The next case I shall relate is quite as good a type. 
This was a lad, aged fourteen, who was taken from 
school a few months before on account of twitching 
and nervousness. He had become also irritable and 
capricious, and the grimaces, for which chiefly he 



160 DISEASES OF THE NERVOUS SYSTEM. 

was brought to me, had increased, and had, indeed, 
been increasing from the previous April, and until 
he gave up school, late in July. It is, in fact, 
usually safe in such cases as this, and in all choreal 
troubles, to predict either a return or an increase 
of the symptoms in the spring. 

In this lad the twitches began with snapping of 
the eyes, and this came and went, but was never 
quite lost, but merely lessened when some new 
symptom arose. The second form of trouble con- 
sisted in a curious rolling of the head, difficult to 
describe. This was bad enough, but quite suddenly, 
within a few days, the face became more quiet, and 
there arose a disorder of the abdominal muscles, 
which were abruptly contracted at intervals. Over 
this and over all these motions my patient had a 
good deal of control. If he set himself to hold it 
in check, this was possible so long as he steadily 
attended to the task, but while it was easy to repress 
it for fifteen minutes it was difficult after half an 
hour, and increasingly more and more hard, until 
by and by some slight lack of attention enabled the 
act to recur, or else the sense of discomfort and 
strain involved in these resolute acts of will power 
became unendurable, and the lad abandoned the 
effort. After a month or two of these movements, 
the respiration was broken every few minutes by a 
long drawn, abrupt inspiratory act. Still later the 
head was affected, or rather the neck, with a 
little, short, negative shake. The abdominal and 
respiratory disorder gave way at last to shrugging 
of one shoulder, and then to this with a queer up- 



HABIT CHOREA. 161 

ward pull of the whole side. The worst attack 
lasted but a few weeks, and was a sort of straighten- 
ing up of the body. These varying conditions 
endured for several years. At one time the boy 
seemed well, then spring-time or any little malady, 
especially indigestion, or much study and in-door 
life, seemed to reproduce the troubles in some shape 
new or old. It was a slight grimace to-day, and in 
a week or two it was a sudden action of the muscles 
of the back or a shrug or a spasm of the muscles of 
the belly. In no case did the hands or feet suffer, 
and always the disorderly act was distinctly con- 
trollable by will; this repression was unpleasant, 
and some relief was found in allowing the muscles 
to have their way. 

As the patient's eyes were plainly imperfect, Dr. 
Noyes, of New York, was so kind as to send me a 
statement to the effect that the lad had, in the right 
eye a slight mixed astigmatism, and in the left a 
slight compound hypermetropic astigmatism. These 
errors were really trifling in amount. The eye mus- 
cles showed some weakness. The eye-grounds were 
healthy. 

I had a long bout of treatment with this lad, whose 
docility and good sense lent me every help. 

He took at first a good deal of valerianate of zinc, 
and had cold douches to the spine, and also arsenic 
internally. Meanwhile he was taken from school and 
set free in Virginia on the seacoast to ride, swim, 
shoot, and fish. Notwithstanding these wholesome 
aids, we got no further in the way of relief until we 
began to use hypodermic injections of arsenic. For 

14* 



162 DISEASES OF THE NERVOUS SYSTEM. 

this Fowler's solution without the lavender was used 
thrice a week, in doses rising from two drops to 
twelve, and as this heroic medication was followed by 
rapid subsidence of the symptoms, it was continued 
for nearly three months. A sea-voyage and residence 
at an English school completed his cure, and then 
we had also the favoring influence of approaching 
puberty. 

These cases, and I might readily add others, suffi- 
ciently illustrate the varieties and the peculiarities of 
the disorder to which, for reasons which must now be 
plain enough, I have with some hesitation given the 
name of Habit Chorea. The last case also defines suf- 
ficiently well w T hat the treatment ought to be. 



DISOKDERS OF SLEEP. 163 



LECTURE X. 

SOME DISORDERS OF SLEEP IN NERVOUS OR 
HYSTERICAL PERSONS. 

The man before us is a feeble ansemic creature, 
who complains that he has become nervous, an ill 
sleeper, and has lost weight. He is a coffin maker, 
and looks as if he were artistically fitted for some 
such ghastly labor. He has no organic malady, and 
I only speak of him at all because one symptom of 
his case is of sufficient interest to serve as a text. 

He tells his story well, perhaps more dramatically 
than I can, but with less brevity than I need just now. 
When failing asleep he is conscious of something in- 
definable, not describable, rising from his feet and 
going up to the head. Usually he can move and thus 
check the progress of the disorder; sometimes he can- 
not, and then the attack results in a sense of some- 
thing like a blow struck on his head. At first it 
created terror, now he has become used to it, and is 
no longer alarmed, although the expectation of it is 
unpleasant, and apt to keep him awake. 

This is a mild form of a very curious symptom — I 
can hardly call it more — wdiich is quite common 
among hysterical women, more rare among men, and 
which exists in a variety of forms, and is in such 
persons at times a difficult symptom to deal with, and 



164 DISEASES OF THE NERVOUS SYSTEM. 

in certain cases the parent of a great deal of mischief. 
In 1875, I published a brief paper 1 on some of the 
disorders of sleep, in which I described these phe- 
nomena as follows : 

" The trouble I shall describe is rarely found alone, 
but makes a part of one of those groups of neurosal 
symptoms which have no place in the books, and 
which are apt to vary largely. 

"M. A., a prominent physician from the Northern 
States, after a season of greatly excessive labor, be- 
came rapidly anaemic and weak, and developed the 
following symptoms : tingling, numbness, and heat of 
the extremities — now here, now there — on the chest, 
face, or scalp. At times, after much fatigue, islands 
of vasal paresis, seen as slightly raised purple blotches 
on the feet, are observed, and frequent waking up at 
night, with numbness of either arm; feeble sleep, a 
dull, occipital pain, which made him wish to hold the 
part; singing in the head, referred now to the occiput, 
now to the ears, but an inconstant symptom. He 
was at last driven to consult me by the following 
symptoms, which caused him the utmost alarm. 

" When just falling asleep, he became conscious of 
something like an aura passing up from his feet. 
When it reached his head, he felt what he described 
as an explosion. It was so violent and so loud, that 
for a time, he could not satisfy himself that he was 
not hurt. The sensation was that of a pistol-shot, or 
as of a bursting of something, followed by a momen- 
tary sense of deadly fear. This sense of an aura is, as 
Brown-Sequard truly says, not confined to epilepsy. " 

1 Virginia Med. Monthly, Feb. 1876. 



DISORDERS OF SLEEP. 165 

I have now in my care, a very accomplished gen- 
tleman, whose case is in almost every respect like that 
just sketched, except that the numbness is never uni- 
versal. The victim (Mr. V.) is, in this instance, a 
slight sensitive scholar, not overworked, but too 
steadily worked, which may amount to the same 
thing. In him, the numbness of the finger-ends came 
on abruptly, but, as in the other case, there is no true 
loss of tactile sense, and possibly, nay probably, the 
feeling belongs to some condition of the lesser blood- 
vessels of the part, and only secondarily to the nerves. 

He feels, as he is falling asleep, a sense of something 
about to happen, but no distinct ascending aura. If 
he arouses himself in time, for which at the moment 
he clearly comprehends the need, he can by turning 
over relieve himself and break the chain of morbid 
events. He can even watch, as it were, the coming 
of the shock, and in some way know the moment be- 
yond which he must not wait. The first patient de- 
scribed as suffering in like fashion has also remarked 
on this peculiarity. Mr. V. has rarely the sense of a 
pistol-shot or a blow on the head. " I have," he says, 
" at the close of the attack, a noise in my head, which 
is sometimes like the sound of a bell, which has been 
struck once, and I have in my case listened as to a 
bell, to the vibration coming and going at rhythmical 
intervals, or else I hear a loud noise, which is most 
like that of a guitar string, rudely struck, and which 
breaks with a twang." The result is always, how- 
ever, a sense of dread, but not such a death terror as 
has Mr. A. 

I have been told by other persons, that they were 



166 DISEASES OF THE NEKVOUS SYSTEM. 

liable, when going to sleep, to have sudden sounds, 
faint usually, and rarely loud, but without feeling of 
terror. 

Since writing this account, I have seen a large 
number of persons who suffer in like fashion from 
some one of the various forms. The most of the 
cases are women worn out, or tired out, and hysteri- 
cal, whether strong and well nourished or not. In 
sturdy men it is rare, unless they be excessive users 
of tobacco. 

The disorder in question I never saw in a man, ex- 
cept in the border-land between walking and sleeping. 
He may have the aura and then the subjective sensory 
phenomenon, or the latter may come without warn- 
ing; but in hysteric females these attacks may arise 
either at the moment of going to sleep, or during the 
day at any time, and while fully awake. At times 
they are slow in the march of their symptoms, and 
may be checked by the patient if, what is rare, she 
have enough of resolution ; but very often the aura 
rises fast, too fast to allow of action or of emotion, 
or else just slowly enough to give time for a sense of 
fear, the full development of which requires a certain 
amount of time. 

The warning by an aura is common in women thus 
attacked, and consists either in an indefinite sense of 
something rising towards the brain from the feet or 
hands, or both, or else it is a distinct tingling. 

In a smaller number of cases the only warning 
is an impending sensation of pure terror, which 
increases until the sensory shock occurs. But as 
regards all forms of the aura, or warning sensation, it 



DISORDERS OF SLEEP. 167 

is found that, as a rule, the intensity of the emotion 
weakens with repetition. 

The aura is totally lost in the phenomena which 
follow. These may be classified as follows : 

1. In the sphere of general sensation : sense of a 
blow, of shock on or in the head, of rending or 
bursting. 

2. In the auditory sphere : loud noise like an ex- 
plosion. 

3. In the visual sphere : flash of light. 

4. In the olfactory sphere : sense of odor. 

5. A combination of two or more of these sensory 
manifestations. 

6. More or less abrupt and general motion, the 
ordinary outcome of any violent and sudden sensa- 
tion. 

It will repay us to analyze somewhat more minutely 
the peculiarities of these interesting attacks, since I 
have usually found that they are not only sources of 
alarm to patients, but of doubt and puzzle to their 
medical attendants. 

In the first group the final symptom is referred to 
the head, and is a feeling of a blow, violent or light, 
struck on the skull ; or it is a feeling so terrible as 
to be described as something like an explosion, or a 
pistol-shot, or more vaguely as a shock, something 
undefinable and terrifying. 

The auditory forms are described in their varieties 
as a noise, an explosion, the sound of a bell, a boom- 
ing sound— that of a guitar-string rudely struck. 

The visual form is simply a flash of light, with or 
without sense of noise. 



168 DISEASES OF THE NERVOUS SYSTEM. 

The single case of an olfactory form of sensation 
will be more fully described hereafter. 

The affections of general sensation may exist with 
auditory symptoms or not, since, when it is possible 
to get a patient to evolve, out of the terror and con- 
fusion of such attacks, an analysis, they usually men- 
tion some disturbance of audition as going with the 
sense of a blow. 

In rare cases the patient is left with a momentary 
vertigo; more often the start which announces the 
sensory symptom ends the attack, so far as its imme- 
diate phenomena are concerned. Not so, however, 
its results in the emotional sphere. In some persons 
it gives rise to great alarm, even after many repeti- 
tions of attacks, and in these and others is apt to 
leave the victim shaken and hysterical, or to be the 
first of a series of hysterical symptoms, the end or 
exact future of which no man can predict. 

I would like now to illustrate some of these in- 
teresting symptoms by cases, always asking you to 
remember that in this lesson, as in some others, I am 
picking out a single symptom for study, and that it 
is not always the main feature. 

The following case is told so well in the language 
of the sufferer that I prefer to leave her account 
almost unaltered. It is one of a few rare examples 
in which the shocks occurred at times while awake 
as well as during the state of sleep. A series of 
severe mental and physical strains, and a slight sun- 
stroke left my patient, a woman, now over fifty, 
anaemic and reduced to the weight of seventy-six 
pounds, her height being five feet three inches. 



DISORDERS OF SLEEP. 169 

Her eyes and ears were healthy, her womb normal. 
There was no trouble of any internal organ, but there 
was a loud soft hsemic murmur at the right side of 
the base of the heart. Her sleep was good as a rule, 
but was easily disturbed and insecure. She writes 
thus : " Some years ago, when thirty-nine years old, 
after a long bout at nursing, sustained by quinine 
and stimulants, I began to fail in health, and then 
first became subject, whether asleep or awake, to a 
sensation, which I can only describe as a wave going 
through my head and threatening, as it seemed to 
me, an unconsciousness which never came. If in 
bed, I would start up, and if riding or walking would 
clutch at some near object for fear of falling, yet I 
cannot remember to have felt unstable. The fol- 
lowing summer, after slight heat-stroke, and a new 
exposure to severe fatigue of body and mind, I ex- 
perienced, once only, a sensation like the explosion 
of a pistol in my head. I hardly know how other- 
wise to describe it. A few months later, I began to 
have what I have always since called my shocks. A 
peculiar something, which for want of a better name 
I call electricity, starts from my head, chest, stomach, 
or bowels, and seems to pervade me in a flash, then 
comes the sense of shock in the head and an uncon- 
trollable shriek. At first, it never came unless my 
eyes were shut, but for one week, when I was most 
highly nervous and sleepless, it would come if I was 
startled by any sudden sound, and then I found that 
for a short period I could cause it by touching a spot 
over my stomach. 

"Of late, these shocks are not always preceded by 

15 



170 DISEASES OF THE NERVOUS SYSTEM. 

any length of warning, and are in the head alone. 
They come mostly as I am going to sleep, and by 
straining my eyes to keep them open, I can some- 
times prevent the shocks altogether. I should say, 
that there is often some queer sense of chilliness in 
my head for an hour before the shocks, which is in 
a general way a warning of what may come. I do not 
like so to restrain them when the tendency is strong, 
as I then have one or two during the night while 
asleep, when they are very frightful to me. In some 
cases there will be a succession of w T eak shocks, and 
at last a strong one, when I shriek. After absence 
from home and freedom from cares, I have been 
exempt from these shocks for weeks or months." 

This unhappy case I mention first, because of its 
obstinacy. I have rarely seen the shocks thus per- 
sistent, and I am sure that they will disappear when- 
ever this woman becomes vigorous. Neither is the 
case quite typical, like one I have lately seen, and 
which readily got well. It is valuable because the 
shocks were so much the most prominent symptom. 

Early this winter, Mrs. L., of Massachusetts, set. 45, 
a ruddy, hale looking woman, five feet four, weight 
156 pounds, came to me with this simple story: She 
was well until her husband met, a year ago, with dis- 
asters in business. Her anxiety about him, and the 
worry attendant upon the management of a house- 
hold with suddenly lessened means, were made worse 
by the grave illness of her only child. She became 
nervous under these influences, and began to suffer 
from sounds which commonly cause no annoyance. 
Then her sleep got to be imperfect, and she had a 



DISORDERS OF SLEEP. 171 

series of hysterical attacks — the usual spasms — tris- 
mus, rigidity, hysteric coma, and the like, with a 
slight but distinct and general lessening of acuity 
of the sense of pain and that of touch. Finally these 
phenomena passed away, and about this time she 
became subject to the shocks I have spoken of. 
These occurred either at the moment of going to 
sleep, and while quite conscious, or in the day-time, 
and when wide awake. 

The aura began in both feet, and ascended rapidly 
to the head, sometimes being felt also in the hands 
and arms. It was described as an air, and at times 
as a faint tingling. It ended in a sudden sense of a 
loud report, which caused her to seize her head with 
both hands, and left her in a state of alarm and fee- 
bleness, and with a brief but tumultuous throbbing 
of the heart. The attacks took place irregularly, 
once a week at first, and later at much longer inter- 
vals. Their effect was disastrous, because they gave 
rise to distressing nervousness, and sometimes to pro- 
longed hysterical conditions, in which all her usual 
hypersesthetic states were remarkably accentuated. 

While she w^as under my care I saw a lady from 
New York who was a sufferer from a variety of ner- 
vous symptoms, dependent in part on a split cervix 
uteri and a lacerated perineum. These were sur- 
gically relieved through operative means by Prof. 
Goodell, but the after-treatment of the hysterical 
conditions, hyperesthesia, sleeplessness, and intense 
general nervousness was a slow process. The use 
of ether during the operation, which I have learned 
somewhat to dread in grave hysteria, seemed to be 



172 DISEASES OF THE NERVOUS SYSTEM. 

the immediate parent for a time of an increase in all 
her old symptoms, and of some new ones, among 
which were the shocks. 

The attacks came at any time except in sleep, 
and were similar to those of Mrs. L., but less severe. 
There was no aura, unless we can so call a feeling of 
impending peril, which lasted a few seconds, and 
ended in a sensation of a blow on the head. The 
attacks ceased after a month, and have never re- 
turned. 

The next case I have to relate was more curious. 
A girl, set. 18, was placed in my care some years 
ago suffering from a slight unilateral hysterical paral- 
ysis, with well-marked anaesthesia. She was far less 
nervous than the woman 1 have described, and, in 
fact, it is, I think, not rare to find that women with 
distinct hystero-palsies are, if we omit ovarian ten- 
derness, fairly free from the various hyperesthesia 
which constitute one of the groups of hysteric symp- 
toms. She had, how r ever, attacks when going to 
sleep, in which she became conscious of a something 
which seemed to ascend from the feet to the head. 
If she could rouse herself, or turn over, the attack 
terminated, and usually did not recur that night. 
It sometimes happened, however, that she was not 
able to act in time, or was clearly conscious that she 
could not, in which case there was a wild flash of 
vivid red light, and she was at once seized with dis- 
tressing nervousness, and sometimes with tremor. 
I do not remember that the attacks ever took place 
when awake, while it is as certain that they never 
occurred during sleep. 



DISORDERS OF SLEEP. 173 

The next illustration of the double sensory dis- 
charge giving rise to subjective feelings of sound and 
light is valuable, because the account is given to me 
by the sufferer, a medical officer of the United States 
Army, R. M. O'R., set. 35, married, parents living, 
both of gouty diathesis. He is, and always has been, 
strictly temperate in all respects. Smokes in mod- 
eration. When twelve years old, had a sharp attack 
of intercostal rheumatism. In 1868 contracted ma- 
larial fever, from which he has suffered more or less 
ever since. In 1867 received a trifling gunshot 
wound of right thigh. 1875 had concussion of the 
brain, and some injury to back, resulting from a fall. 
Was confined to bed for a week or ten days, and 
walked with difficulty for some time after. Was 
troubled with vertigo for over a year. Has had no 
other sicknesses nor injuries. 

In June last, wdiile sitting, lost consciousness ; did 
not fall. On recovering saw objects surrounded 
by a halo ; walked home with some difficulty, and 
went to bed; slept none that night, but occasionally 
dozed, and was aw r akened by a sensation of falling, 
or by a sudden noise, or by voices calling. Re- 
mained in this condition for about two days; could 
arouse himself, but as soon as the effort relaxed 
dozed, and had the feelings described. This con- 
dition gradually wore off', leaving vertigo, appreci- 
able muscular weakness (especially of the lower 
extremities), a sense of constriction around the head, 
wakefulness, and want of appetite. 

Late in June came to Philadelphia; consulted 
Dr. Alison, who observed that one pupil was some- 

15* 



174 DISEASES OF THE NERVOUS SYSTEM. 

what dilated. Subsequent ophthalmoscopic exami- 
nation by Dr. Thomson showed that this condition 
had passed awa}^. 

Early in August went to Oswego, and has passed 
the time there and thereabout until a week ago. 
Within the past month has had two or three severe 
headaches, with pain over the left temple. These 
have followed fatigue or excitement. 

At present he can walk but a short distance 
without growing very tired, then come vertigo, 
seemingly confined to the posterior portion of the 
head, and a condition of nervous exhaustion, lasting 
some time. The same effects ensue upon mental 
strain of any kind. He sleeps fairly well. The 
feeling of constriction around the head is constant. 
Appetite variable, but never very good ; bowels in- 
clined to be costive; temper irritable: want of 
capacity to think a subject out, or to decide any 
question; has lost weight. No organic trouble of 
heart, lungs, or kidneys. 

Since June last he has had several shocks, of an 
explosive character, which appeared to be within 
the cranium. They came at irregular intervals, 
and without assignable cause. They have always 
occurred just as he was falling asleep, and have 
been preceded by no abnormal sensations. He is 
awakened by what seems to be a loud explosion in 
his head, accompanied by a flash of white and blind- 
ing light. There is no pain with it, and except an 
acceleration of the pulse there are no sequels. The 
noise thus heard is described as a rather low note, 
accompanied with a feeling as if the head was sun- 



DISORDERS OF SLEEP. 175 

dered by the explosion. The attacks come and go, 
but are always such as to make him dread the going 
to sleep. 

I have notes of a yet more singular case, which I 
hesitate a little, and, perhaps, without due cause, to 
class with these. 

A woman, set. 40, and in good health, was hurt 
during the tumult which followed the explosion of 
the boiler of a steamboat. She was thrown against 
the rail of the boat, striking her nose violently, and 
then fell into the water, whence she was rescued 
insensible. For several w 7 eeks she was very ill, and 
recovering became the victim of acute hysteria, which 
in a year passed away, leaving her feeble and emo- 
tional. Her sense of smell was entirely lost from 
the time of her accident; but she had at times a 
subjective and very annoying impression of the 
presence of an odor of brown soap. 

When I saw her two years after her accident she 
had, at long intervals, these symptoms. At any 
time, awake or asleep, she became aware of some- 
thing like a touch moving over her, usually about 
the epigastrium. After a few moments she expe- 
rienced a sense of shock in the head, usually at the 
back of the head, and with it a remarkably distinct 
sense of a strong odor, like that of bananas. It per- 
sisted for, as she thought, a minute or more, and 
then slowly faded away. 

I have seen a number of these cases of sensory 
shock, and I suspect that, w^hen inquired into, we 
shall find them less rare than might be supposed. 
The instances I have related cover most of the varic- 



176 DISEASES OF THE NERVOUS SYSTEM. 

ties I have seen, and it only remains to say a few 
words as to their clinical relationships, diagnosis, 
and treatment. 

The clinical relationships of these attacks are to 
epileptic fits, and to those well-known, and, I may 
say, normal phenomena of a sudden movement of 
the body at the moment of going to sleep, or even 
at other times, to which I shall presently refer 
again. 

The analysis of the shock attacks is simple. The 
basis is hysterical excitability, or a hyperesthesia 
from tobacco, or overwork with worry. The attack 
itself is preceded in many cases by an aura of some 
kind, which is the first sensory expression of the 
coming disturbance. The aura is a phenomenon of 
general sensation. Then follows a more or less 
violent discharge from a centre of general sensation, 
as of a blow or shock ; or from auditory centres, a 
noise as of a bell, a guitar-twang, or an explosion ; or 
from visual centres, a flash of light ; or, perhaps, two 
centres act at once; and there may be no aura, as in 
many epilepsies. 

The fact that these attacks do in some people take 
place in the waking state, removes them from dream 
phenomena, and from the domain of nightmares and 
of night-terrors; one form of which occurs in the 
interval between sleep and waking, and presents 
some analogies to these attacks of sense-shock. 

In this form of night-terror, which is seen rarely, 
but has often enough been described to me, the 
sufferer is perfectly conscious of the coming on of a 
nameless dread. Something precedes it in the way 



DISORDERS OF SLEEP. 177 

of a warning. He can, by an act of will, escape it by 
motion, or he may watch its onset. When it cul- 
minates it is merely a state of insensate dread or 
terror, without a felt cause, dreamed or other. This 
seems to me, in the mental or mere emotional sphere, 
to be closely akin to the sensory shocks. 

As to diagnosis, I do not see how this disorder can 
well be confused with anything else, unless with the 
minor epilepsy, from which it ought to be easily 
enough distinguished. 

As to treatment there is not much to say, but 
what there is to saj^ is important and interesting. 

As we are dealing chiefly with the nervous mala- 
dies of women, the cases in which sensory shocks 
are caused by tobacco and excess of brain-work do 
not so immediately concern us here. I may, how- 
ever, be permitted to say that in all symptoms 
directly traceable to tobacco there are two remedies 
available while the habit is being broken, strychnia 
and alcoholic stimulus. It should be needless to say 
that the man who orders the latter ought to have 
some security that his patient will not construe his 
orders too liberally. But this is a matter for a 
doctor's conscience; and, at least, he may feel secure 
that a little whiskey at bedtime will correct the evil 
results of over-use of tobacco, and may be left off 
as soon as the tobacco is much lessened. As to 
strychnia no warning is needed ; and Dr. Landon B. 
Edwards has pointed out, and with reason, that it is 
the tonic most useful in the feebleness which comes 
of abuse of tobacco — that pleasant wife and fatal 
mistress. 



178 DISEASES OF THE NERVOUS SYSTEM. 

As to cases of sensory shock in women, the real 
remedy lies in treatment of the conditions out of 
which it grows. Of these, I have already said 
enough, but there is one matter as to which, in the 
nervous maladies of women, it is hardly possible to 
say enough. 

Perhaps I had better introduce what I wish to say 
in this direction by a brief extract of a letter from a 
woman who has suffered gravely from the shocks I 
have described. She says: "I suffer, as you are 
well aware, from these shocks in the time between 
sleep and wakefulness, and also in the day-time, 
though rarely then. It did not seem to me at first 
possible that I could in any way control these attacks 
or save myself from their results. I found, how- 
ever, that, as I had warning enough, I really could 
do so. So I set myself every night to be resolute to 
turn over or sit up if I had a warning; and every 
day I said to myself, if I have the warning to-day, I 
will not yield, but jump up and run about. To my 
surprise, I found that by following out this determi- 
nation with resoluteness I could break up most of 
the attacks." 

The treatment hinted at in this letter from a clever 
woman is really valuable. It consists in instructing 
the patient before going to sleep, and every day, to 
keep in mind the need to break the attack by motion 
and by an effort of will. 

I do not know of any drug which is directly use- 
ful in such cases of sensory shock as seem too grave 
to await in patience the influence of general tonics. 
The bromides are of value when used in very full 



DISORDERS OF SLEEP. 179 

doses, such, indeed, as it is not well to employ 
long; in the smaller doses in which they do good 
in hysteria, they are, as regards this particular 
symptom, valueless. Small doses of chloral or 
morphia, used until the habit be broken, answer 
well ; but still better is a general improvement in 
health, and then, if the attacks persist, such exercise 
as will insure natural fatigue great enough to make 
it impossible to avoid sleep. 

In the same paper on sleep to which I have already 
alluded occurs some brief account of the motor dis- 
charges which are so familiar to us all as taking 
place just at the moment of deepening sleep. 

What I pointed out then, and what I wish to re- 
call attention to here, is that this normal symptom, 
if I may be allowed so to call it, does sometimes rise 
into the mischievous position of being the dominant 
difficulty in a case on account of its interference 
with sleep. 

The symptom in question — while it rarely takes 
place except in the interval between waking and 
sleep, and never between sleep and waking— may 
also arise during sleep itself, and cause abrupt dis- 
turbance. I have seen it very troublesome in grow- 
ing lads and in some overworked men; but it is rare 
to find it so strikingly developed as in the case of a 
woman who consulted me to-day. This unfortunate 
person was forty-three, the mother of several chil- 
dren, and of late irregular in her menstruation. I 
was struck with the fact that her color was good, 
but that she was curiously thin and very haggard. 
She is well as to her digestion, but has too much 



180 DISEASES OF THE NERVOUS SYSTEM. 

wind, and finds eating hard work; otherwise she is 
well in the day-time, and can read, sew, walk, or 
drive, as pleases her. Once or twice she has had 
long crying spells, without other cause than a sense 
of the wretchedness of her condition. When bed- 
time comes she goes with fear and reluctance to en- 
counter sleep and the discomfort it brings to her. 
Just as she begins to lose herself, an arm, a leg, or 
the whole body suddenly moves with violence. As 
she awakens, her hands and feet, or either alone, 
twitch for a few moments. Then she settles herself 
to sleep anew, only to repeat the same process, until 
at last she sits up, crying hysterically, or, worn out, 
falls into a slumber seemingly too sudden and pro- 
found to allow of the phenomena I have described. 
Her daughter, who came with her, described these 
nights of suffering as truly pitiable, and told me that 
nothing had as yet seemed to afford the least relief. 

Of late, Mrs. R. J. has been apt to wake up later 
in the night with unilateral tingling, of which I shall 
presently speak more fully. 

You must, of course, consider this as an unusual 
case; but it is just unusual cases which are apt to 
puzzle young physicians; and to be able in such in- 
stances as these to recognize the close kinship between 
an almost natural phenomenon and its excessive de- 
velopment into an annoying disorder, is not only 
comforting to the patient but useful to the physician. 

A good many hysterical women exhibit this symp- 
tom; and in a few it becomes troublesome, either 
by its repetitions, as in Mrs. R.'s case, or, what is 
less common, from its severity. A quite ludicrous 



DISORDERS OF SLEEP. 181 

example of the latter I saw a few years ago. The 
patient w^as one of those stout, ruddy women, with 
good ovaries, and uterus where it should be, and 
yet hysterical to an exasperating degree. She 
weighed over 200 pounds, and was unhappily sub- 
ject to what she called " fish-flaps/ 7 which were really 
remarkable, because her body would be thrown up 
from the bed so high, and descend with such violence 
owing to her weight, that it was not rare to find the 
slats of the bed giving way. She grew better as her 
hysteria lessened, but is, I believe, still subject at 
times to these unpleasant and undesired gymnastic 
symptoms. 

There is yet another and a very interesting sleep 
symptom seen at times in some spinal maladies, and 
in a variety of degrees in feeble and ansemic per- 
sons; but far more common among women than 
among men. I ventured some years ago, in speak- 
ing of it, to call it "night palsy," or " nocturnal 
hemiplegia." Since seeing more examples I perceive 
that brachial monoplegia is its most common ex- 
pression. 

This curious symptom assumes one of two forms 
— -the one common, the other rare. In the more 
usual cases the sleeper awakens with numbness, or 
rather tingling and numbness, of one arm, or of a 
leg only, which is infrequent, or the whole side, in- 
cluding the face, and even the tongue, which is now 
and then attacked alone. The disorder may be mere 
tingling, or actual loss, or rather lessening of tactile 
sensation ; but in any case it rapidly fades away, or 
yields to a little friction. At first, when it is confined 

16 



182 DISEASES OF THE NERVOUS SYSTEM. 

to the arm, the patient refers it to lying on the part ; 
but this becomes an impossible explanation of the 
hemiplegic examples. 

As I have seen in a month three cases of this 
rather interesting condition, it cannot be very rare. 
It is significant, perhaps, that some persons who have 
gotten pretty well of a hemiplegia of organic cause 
are liable to awaken out of sleep with numbness and 
lessened power of the side once palsied. It is re- 
markable that in the case of Mrs. R. J., of which I 
just now spoke, this same curious functional hemi- 
plegia would at times occur on the same nights when 
she suffered from motor discharges. 

The less common form of night palsy is, perhaps, 
also the more serious, but may be like the usual 
examples, but an expression of hysteria or of the 
exhaustion felt by an ill-nourished brain during the 
long fast of the sleeping hours. In it the patient 
exhibits a far more distinct loss of unilateral power, 
which, however, lasts for an hour or more after 
awaking, and may even become worse for a time in 
place of at once improving. 

I recall very well the case of Mrs. C. L., set. 27, 
who, after profound blood losses in confinement, 
nursed a child, with success, through several men- 
strual periods. She then had an attack of nocturnal 
hemiplegia, which became more grave during some 
hours. She had after this several light attacks, and 
twice well-marked brachial diplegia, which lasted 
but a few hours. I should add, that there was no 
renal trouble, and that she made a perfect recovery. 
Among other milder forms of trouble, which at 



DISORDERS OF SLEEP 183 

times haunt the sleep of nervous or hysterical fe- 
males, are palpitation of the heart, vertigo, and a 
certain failure of the respiratory centres, which is 
met with also in grave shape in some cases of Du- 
chenne's disease, or in any very feeble people, and 
is, of course, not confined to women. 

In locomotor ataxia, towards its paralytic stage, 
this symptom is but an expression of a defect in the 
medulla oblongata, and has twice in my knowledge 
finally resulted in sudden death during sleep. In 
weakly and hysterical people it means simply a tem- 
porary failure of function, owing to imperfect nutri- 
tion. 

The centre remains competent so long as the will 
is free, during the waking hours, to assist the auto- 
matic activity of the ganglia, but when sleep leaves 
the regular succession of respiratory acts to the un- 
aided powers of defective nerve-cells, there sometimes 
comes a moment of temporary incompetence, and 
the patient wakes up gasping and alarmed. 

The best remedy for these troubles is to be found 
in general treatment, of which I have already said 
enough, and in great care to supply nourishment 
at bedtime, and if needful to repeat its use during 
the night. Of course I take it for granted that every 
care shall have been given to the state of the stomach 
and bowels; and I may add, finally, that some pa- 
tients suffer less, or not at all, if lying on one side 
or the other, or on the back, the best position being 
purely a matter of experiment. 



184 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE XL 

VASO-MOTOR AND RESPIRATORY DISORDERS IN 
THE NERVOUS OR HYSTERICAL. 

I have over and over called attention in mv clinics 
to some of the many and curious vaso-motor disturb- 
ances which we see in such great variety among 
nervous women. From the heart to the capillaries 
we are liable to meet with conditions of disorder, 
which are sometimes almost as lasting as if they 
owed their parentage to obvious and coarse structural 
lesions. This indeed is a familiar fact which I have 
had ample opportunity to verify both in my clinic 
and in my private practice. ~No matter what be the 
form of general nervousness or the variety of hys- 
terical illustration, the nervous supply of the heart 
or vessels, or both, almost never escapes from bear- 
ing some part of the mischief, and only too often, 
after everything else is well and the patient is afoot 
and able to live as pleases her, she will still be re- 
minded by something in connection with the blood- 
supply and its channels, that they are almost the 
last to regain the vigor and steadiness of health. 

The first point to which I wish to ask your atten- 
tion is the pulse. In the mass of hysterical women, 
and especially in those we see here who are apt to be 
feeble, and easily tired as well as liable to tears and 



VAS0-M0T0R DISORDERS. 185 

to more distinct expressions of the hysteric tempera- 
ment, the pulse is apt to be permanently rapid, that 
is for months or years it may remain 20, 30, 50 pul- 
sations to the minute above the normal number. 
You may see this in a woman who is supine in bed, 
and who for the time presents no startling evidence 
of general disorder. I shall have presently to illus- 
trate this fact by cases. 

But besides the speed of the heart movement 
these cases present also two other phenomena; their 
hearts are irritable and prone to beat rapidly owing 
to causes which are powerless to affect the less ex- 
citable organ of the healthy. Then also with this 
cause of being set going bej^ond their common rate 
these hearts are apt to become irregular, and to seem 
to tumble about in an alarming manner. The care- 
ful study of these well-known peculiarities will very 
well repay us. Therefore, before going further, we 
will linger a little upon the questions connected with 
the pulse-rate and rhythm of nervous or hysteric 
women. 

Out of half a dozen good cases I take two or three 
to enable me to illustrate these points. After that 
I shall point out some of the eccentric pulse symp- 
toms, and then say a few words as to the mode of 
dealing with the irritable heart of the nervous, either 
when it is but a symptom, or when it rises into such 
prominence as to be the dominant mischief. 

There was last year in the Infirmary for Nervous 
Diseases, a lady from Virginia, who presented in a 
typical form the cardiac states which I expect to find 
in neurasthenic women, and especially in such as are 

16* 



186 DISEASES OF THE NERVOUS SYSTEM. 

both feeble and hysterical. She was 38 years old, 
married but childless, and had been for some years 
subject to hysterical attacks, which passing away left 
her at last so feeble that she was unable to walk up 
stairs without great exhaustion. She was five feet 
one, weighed one hundred pounds, and was anaemic 
and sallow. Her uterine functions were fairly good, 
and she suffered no pain and had no distinct uterine 
disease although both ovarian regions were tender, 
and pressure upon them caused nausea and vertigo, 
as well as other phenomena to which I shall presently 
refer. Her digestion was good if she ate but little 
at a time, and was not tired or excited. 

Her heart, when she was lying down, was never 
under 130 beats per minute. Any exertion raised 
it 20 to 30 pulsations. The least excitement did the 
same, but despite this irritability the rhythm was 
always good, and I should add there was no affection 
of the eyes or the thyroid gland. Pressure on the 
ovarian region gave rise to sudden increase in the 
number of heart beats, but pressure on the spine 
almost anywhere had a like influence. She had tried 
absolute rest for a week or two at a time, and had 
taken a large amount of tonics and of digitalis. 
Her temperature was curious, being in the mornings 
97-97.5°, and in the late evening, 9 to 10 p. m., 100- 
101.5°, although there was no pulmonary or other 
visceral trouble. The evening pulse was usually a 
few beats under that of the morning. 

Electricity (induced current, slow interruptions) 
used as a muscular exerciser, and also massage, ex- 
cited her greatly, causing tremor, tearfulness, and a 



VASO -MOTOR DISORDERS. 187 

rapid increase in the pulse. Withal, the heart was 
perfectly healthy as to its valves and its size, 

I began her treatment by using various forms of 
digitalis, but although she took enormous doses, I 
never succeeded in making any impression on the 
heart, and usually this drug seriously disturbed diges- 
tion. I found that frequent small feeding with rest 
somewhat aided her, but although she was thus made 
more comfortable there was no substantial gain, until 
in despair I resorted to CarelPs skimmed-milk treat- 
ment. After three weeks of this I was able to repeat 
the use of massage which I had been forced to aban- 
don. From this time the improvement in flesh, 
color, and self-control was notable. When she was 
able to walk about after two months of rest, the 
heart beat had fallen to 95° and was far less excitable, 
and her temperature had become normal. It re- 
quired, however, many months of care to make her 
circulation quite natural, but within six months she 
became fat (one hundred and thirty pounds), and 
was able to complete her cure by a summer in the 
mountains. 

This was, of course, an extreme case of cardiac 
nervousness, but it is no unfair type, and I need add 
little to the description. Sometimes the tumultuous 
action of the hysterical heart is the most distressing 
and most upsetting of all the many symptoms of this 
disorder, so very fertile in symptoms. We all know 
how unpleasant and appalling even is the sense of 
sudden and great irregular palpitation, and in the 
nervous and hysteric this impression loses nothing 
of its terror. You will meet with such women — 



188 DISEASES OF THE NERVOUS SYSTEM. 

women whose hearts seem to become wildly irregu- 
lar on the least provocation, or on none. Digestion 
in these women causes it, and here I cannot too ear- 
nestly insist that digestion, like some other functional 
acts, may give rise to symptoms which are not of 
necessity proofs that the function in question is im- 
perfect or diseased. Ordinarily, if we have palpita- 
tion of a healthy heart during digestion, that means 
often enough that our patient is dyspeptic, but not 
so in nervous and hysterical women. Digestion 
naturally quickens the pulse, and in these people the 
normal quickening passes into palpitation. That I 
am correct as to this is shown in the same women 
more rarely by the varied disturbances which follow 
the most perfect performance of other normal func- 
tional acts as simple as micturition or defecation, I 
have seen patients in whom bowel movement always 
produced irregular heart action, and I have now a 
lady under my care who has, soon after passing water, 
slight chilliness, twitching of the face, and extreme 
palpitation of the heart. Yet, the act of urination 
is, in this case, painless, and, in fact, absolutely 
natural. You may regard all of this as of trifling 
moment, but I have seen cases like these treated 
with many drugs, and in a case similar to the last 
one I have known a surgeon resort to dilatation of 
the urethra. Bear in mind, therefore, that some- 
times in nervous people the activity of a normal function 
is competent to cause distress in other organs or to awaken 
unusual symptoms. 

The violence and singularity of the pulse-signs in 
true hysteria are beyond expression strange. 



VAS0-M0T0R DISORDERS. 189 

I saw, very many years ago, a handsome girl, of 
twenty, from Cincinnati, who had spells of apparent 
death, if I may use such a term. One of these I had 
the gQod fortune to see, and, indeed, to cause, for 
having been warned that, to speak before her of cer- 
tain things, was apt to cause the trouble, I unluckily 
began to discuss with her the subject of a personal 
peculiarity, from which I had been told she suffered. 

It seemed that certain odors would, in her, bring 
on hysterical attacks. You may recall a case here, 
last week, of an aphonic girl, in w T hom musk would 
do this. Now, my patient had at last become very 
sensitive as to this as to other matters, and no one 
near her ventured to talk about odors; since then it 
seemed that the young lady was liable to suffer, as 
if from the odors themselves. Of late the hystero- 
epilepsy had given place to the " Death spells," as 
her friends called them, and it was one of these I 
provoked. She said to me, "I am going to have an 
attack; feel my pulse. In a few minutes I shall be 
dead." Her pulse, which just before was about 100, 
was now racing, and quite countless; while the 
irregularity and violence of the heart's action seemed 
to me inconceivable. With the interest of an hys- 
terical woman in her own performances, she said to 
me, "Now watch it; you will be amazed." This 
certainly was the case. Within a few minutes the 
pulse began to fall in number, and, as well as I can 
recall it, in some fifteen minutes was beating only 
40. Then a beat would drop out here and there; 
the pulse meanwhile growing feebler, until at last I 
could neither feel it, nor yet hear the heart. In 



190 DISEASES OF THE NERVOUS SYSTEM. 

this state of seeming death, white, still, without 
breathing or perceptible circulation, this girl lay for 
from two to four days. In this time there were 
spells of a few minutes, during which the heart beat 
again furiously and irregularly, as was also the case 
w^hen she revived. 

Of course, emotion of any kind is, in these women, 
able to disturb the heart rhythm and its number ; 
and while such persons are subjected to the contacts 
of daily life, it is therefore hard to relieve them. 

The oddities of hysterical cases are perceptible 
enough in the way in which the heart-action seems, 
at times, to disobey all apparent laws. I have seen 
such persons, whose hearts beat slow T er when they 
rose, and faster when they were lying down. I have 
now a patient, whose heart is quiet enough while she 
is supine, but to lie on either side causes palpitation 
and increased rapidity of pulse. 

There are now in the Infirmary two cases of 
great general nervousness with hysterical histories. 
Neither has organic disease. The one has an aver- 
age morning pulse of 100, and a night pulse of 75. 
The other nearly reverses these numbers, but I have 
been utterly unable to find a precise cause for these 
peculiarities. 

Apart from cardiac troubles and arterial throb- 
bing, or in relation with them, are certain vaso- 
motor disturbances which give rise to very distress- 
ing, or, at least, to annoying troubles in this class 
of sufferers. 

Every hysterical woman is liable to a certain want 
of tone in the surface-vessels w T hich gives rise to a 



VASOMOTOR DISORDERS. 191 

group of disorders, owing to which we meet with 
extreme states of pallor or of flushing which in some 
cases affect the extremities and in others are most 
visible in the face. This want of steadiness in the 
vessels of the skin belongs to some extent, and 
naturally, to others than the class I speak of, and is 
seen very well in certain healthy women of fair 
complexion, and is also common in persons who are 
liable to the congestive type of neuralgic headaches. 
Watch one of these women, and if they have this 
peculiarity in a high degree, it will come out under 
the excitement and embarrassment of clinical ques- 
tioning. You will then see the face flush, and the 
flush by degrees break up into spots of red which 
move slowly and have bounding margins of pale- 
ness ; and all this will be best seen on the neck and 
cheeks and below the ears. At the same time the 
hands and feet may become cold, and, at all events, 
you will find that almost incurably cold feet are the 
constant annoyance of these patients; and some- 
times the cold feet are pale; and sometimes, in 
graver hysterical cases with palsy or sensory defects, 
they may be purplish ; and both appearances indi- 
cate, as you know, defects of blood-supply, and both 
lead to like results. 

Another and very remarkable indication of the 
acquired sensitiveness of the surface-vessels in cases 
of the hemiplegia of hysteria is the well-known fact 
that any moderate traumatic injury to the skin- 
vessels gives rise to their instant contraction, so that 
slight wounds which usually bleed do not do so in 
them. I have seen this state of things in hysterical 



192 DISEASES OF THE NERVOUS SYSTEM. 

girls who were not suffering from analgesia, but in 
most cases it is found over a half of the body affected 
by some loss or lack of feeling of some kind. As 
the feeling improves, the needle wound bleeds, and 
whatever aids the one condition helps the other, so 
that, when from the use of metals the phenomenon 
of transference of the anaesthesia to the opposite 
limb occurs, it is at once found that needle wounds 
cease to bleed on the side attacked, and bleed on 
that deserted by the disease. As I said in a former 
lecture, I have myself been unfortunate in never yet 
having been able to see the phenomenon of transfer. 
I have several times seen metals laid on the anaes- 
thetic parts give rise to some partial return of feel- 
ing and of bleeding from needle-pricks, but I have 
seen caoutchouc and wood, and even sponge do the 
same; and the effect of a blister and of the rhigo- 
lene spray can be seen in a patient now in the wards. 
I may add that dry cups and mustard have also 
given me the same results. There may be indeed 
some unsuspected relation between loss of sensation 
and the bloodlessness of slight wounds, for in one, 
at least, of those remarkable cases of total surface 
anaesthesia to all forms of sensory impression, a 
case of profound melancholia, although the loss of 
feeling extended to the face and mouth, and was 
certainly not hysterical, the surface was made to 
bleed with the most extreme difficulty. The same 
phenomenon of failure of pin-pricks to bleed has 
been recently observed by me in a man with hemi- 
anaesthesia of cerebral and organic cause. It seems 
likely that cutaneous ischaemia is to be added to the 



VAS0-M0T0R DISORDERS. 193 

list of symptoms which Charcot has pointed out as 
common to hysteric hemi-palsies, with loss of pain- 
sense, and the hemi-ansesthesia of more definite 
cause. Since I was led to suspect that there is some 
link of relation between anaesthesia and surface 
failure to bleed, I have been on the lookout for a 
case of nerve section in which to test the matter. 
Two days ago Dr. R. J. Levis cut the sciatic and 
crural nerves in a man who has a deep and incura- 
ble ulcer of the left leg. The operation deprived 
him of all sense below the middle calf, and I was 
enabled, with Dr. Levis's permission, to examine 
the case in his ward at the Pennsylvania Hospital. 

All forms of sensation were extinct in the foot. 
Using a very large needle, I left it in place some 
time, or turned it about freely, but was unable to 
cause a single drop of blood to flow from these re- 
peated wounds. As I withdrew the needle, a small, 
snow-white ring, slightly raised, formed around the 
orifice, and seemed to be due to contraction of the 
neighboring skin muscles. This most interesting 
observation confirmed for me what already I had 
seen some years ago in other and less extensive nerve 
sections. I had, however, continued to doubt the 
correctness of the former observations, which were 
made in cases of division of ulnar or median trunks. 
It certainly seems as though the loss or lessening of 
sensation were associated with the taking off from 
the skin vessels of some inhibitory influence, thus 
leaving them to contract with violence under the 
influence of any irritating cause. All explanations 
may admit of question, but as to the fact to be ex- 

17 



194 DISEASES OF THE NERVOUS SYSTEM. 

plained, I think there can be no further doubt. I 
hope that I have here said enough to direct attention 
anew to this interesting phenomenon. 

Temporary flushing or pallor of face is very apt to 
accompany sudden and irregular heart action, and 
to become and remain a distressing symptom. Why, 
with a perturbed heart, one woman should have a 
deadly paleness, and another a profound flush of face, 
I cannot say, but both sets of conditions are familiar 
to me. Now, as in such females the heart becomes 
agitated, and the face red or white on the least 
provocation, or on the mere expectation of it, you 
can readily see what an annoyance it may become. 

I saw last year a bright, intelligent New England 
girl, who, with much general nervousness, had also 
a heart far too rapid, but besides its speed, if she 
met a friend suddenly, or went into a drawing-room, 
or was even spoken to unexpectedly, her heart be- 
came irregular, and her face very pale. You may 
readily imagine to how much misconception such a 
disorder might give rise. The longer it lasted the 
worse it became, and one pleasure or one duty after 
another was given up in turn, because of the shame 
to which every mildest emotion subjected her. After 
long treatment she became well as to most of her 
ailments, but had been a year in seeming health be- 
fore her circulation reacquired the proper tone, and 
she could again face, without fear, all the trials of 
social life. 

Flushing with tumultuous heart action is more 
common, and is, I should say, more like an exag- 
geration of a common functional event of health. 



VASO-MOTOR DISORDERS. 195 

Still, when it occurs habitually on the least emotion, 
it is, like any such symptom, a source of most bitter 
annoyance. 

Unilateral, or strictly local flushing, is, I suspect, 
a very rare affection, either in hysteria or elsewhere, 
but, of course, the best examples are to be found in 
hysteria. 

Last year I was consulted by a lady, both of whose 
legs were as red as blood in excess could make them, 
and this state came on after many months of varied 
hysteric troubles. Excepting an imperfect paraplegia 
these had all passed away for the most part, but 
whenever she sat up, her legs filled with blood and 
looked as if they might burst. Unlike cases of ery- 
thromelalgia there was no pain, and when the limbs 
were elevated they slowly got back their color. Pin- 
pricks bled easily, and there was no loss of feeling. 
I watched this singular condition for some weeks, 
every effort failing to relieve it, and finally, I may 
add, that when it was let alone, and only the consti- 
tutional state was looked after, the local paralysis of 
vessels gradually got well. 

I have over and over seen this vasal paresis in the 
hands of these women, and one distressing case of 
intense and permanent redness of the face, which 
took, at first, a unilateral form, and then attacked 
the entire face in spells. These began at any time, 
but chiefly in the morning hours. A spot of color 
came anywhere on the face, went and came, and at 
last others appeared. These coalesced after a time, 
and the color deepening the face, scalp, ears, and 
upper neck at last looked like those of a heavy 



196 DISEASES OF THE NERVOUS SYSTEM. 

drinker. There was no pain, or only a sense of un- 
comfortable fulness and heat. The eye-ground did 
not seem to share so fully in the vascular fulness, 
but the depths of the ears did. Relief was obtained 
by a spray of cool water, which did best at a tem- 
perature of 50° to 60° F. If let alone, the redness 
passed away slowly within three hours. At first, 
and at times afterwards, the heart's action was dis- 
turbed a little. I should add that very prolonged 
use of digitaline seemed, with care of the general 
health, to do the most towards the complete relief 
of this unhappy patient. 

The last case of hysterical vaso-motor manifesta- 
tions which I shall quote was so amazing that if I 
had not had the good fortune to see it over and over, 
and to show it once to my friend Dr. William V. 
Keating, I might reasonably have hesitated to tax 
the credulity of my hearers. 

Some twenty years ago I attended a young mar- 
ried woman, whose life was embittered by losses of 
property, and by the ill-treatment of her husband, 
who finally deserted her. For a long period she ex- 
hibited, at times, hysteric disorders in the forms of 
spasms, rigors, hemipalsies, and at last, for a month 
or two, moderate maniacal excitement. With favor- 
ing circumstances she at last got well, and removing 
to the West, was lost sight of until about ten years 
ago, when I was called to see her at a hotel in Phil- 
adelphia. At this time my patient was 35 years old, 
was irregular as to her monthly flow, and had, as I 
found, a womb tilted forward, but not diseased, and 
no ovarian tenderness, or, at least, no tenderness of 



VASOMOTOR DISORDERS. 197 

belly which was not the same everywhere. She was 
rather pale, and very thin, and had a relaxed pendent 
abdomen marked by the scars of four pregnancies. 
I could find no disease of heart, lungs, or kidney. 
She gave me this brief history : After some years of 
ease and comfort, she had been led to risk her prop- 
erty in a wild speculation which ruined her, and now 
she was keeping a boarding house, in New York, 
and was doing well, or likely to do well, except for 
the strange malady on account of which she came 
to consult me. After her new misfortunes she had 
some hysterical troubles, but these ceased to annoy 
her, and she began to observe that at or about the 
time of her menstrual flow, and afterwards at any 
time, she was liable to have an enlargement of the 
belly, which did not seem to her to be due to wind, 
as with that form of swelling her previous experience 
had made her but too fully acquainted. The trouble 
became by degrees w T orse, and at last was so extreme 
as to cause certain unpleasant feelings, and to subject 
her to suspicions of being pregnant. 

The swelling was certainly caused at times by 
emotion. It began at any time, rarely at night. 
Within a few hours the belly, in place of being 
flaccid and pendent, w r as swollen enormously. She 
looked, in fact, as a woman, thin as she was, would 
have looked at the eighth month of pregnancy. 
Other attacks were less severe, but always they 
lasted for some hours before she could stand up, and 
it was usually a week before she was well. 

When I saw her an attack was at its worst. The 
woman's pulse was about 165, and was a mere thread 

17* 



198 DISEASES OF THE NERVOUS SYSTEM. 

at times imperceptible. Her face and limbs were 
white and cold. The abdomen was tense and red, 
and could be felt to throb distinctly, while all over 
it the vessels, veins, and arteries were visibly en- 
larged, On listening over the belly I could hear a 
humming noise, a slight thrill. The chest itself was 
not quite so pale as the neck or face, but the breath 
w r as difficult and rapid. It was clear that owing to 
palsy of all the abdominal vessels, all the available 
blood of the body of a too bloodless woman was for 
a time in this cavity and its walls. If while in this 
state she sat up she instantly fainted, and it was 
difficult even to lift her head, because of the symp- 
toms thus caused. She herself complained of the 
tension of the belly, and of the distressing pulsation 
within it. 

The day after, the abdomen was certainly a third 
less, and it was then seen by Dr. Keating, who, like 
myself, could give no other explanation of the con- 
dition seen, than the one I have just mentioned. 
After a week the belly became nearly as flat as usual, 
and I then ceased to see my patient. I learned from 
her some years later that by slow 7 degrees she had 
become well of this singular malady. 

Yet a few words before I abandon this subject as 
to the irregularities of breathing in the hysterical. 
These may accompany cardiac disturbances, which 
is rare, or may exist alone, without elevation or 
altered rhythm of pulse. In other forms of disease, 
as you well know, w^hen the breathing becomes 
rapid, the pulse also proportionally increases in 
number; and it is uncommon to see excitement of 
heart from fever or inflammation without a like rise 



VASO-MOTOR DISORDERS. 199 

in the rate of respiration ; but hysteria breaks all 
laws, except its own rules of eccentricity. 

I have seen a woman with a respiratory rate of 
10, and a pulse of 100 ; another, with a pulse of 30, 
and a normal speed of breathing. 

There is now in this hospital a case of hemi-anses- 
thesia and hemiplegia, getting well after two years 
in bed. When she began to walk about, two months 
ago, her pulse was 60 to 70; her respiration 15 to 
18. My assistant soon after observed that the rate 
of breathing was increasing, and, without calling 
attention to it, we began to keep daily notes of it, 
and of the heart and temperature. 

The average pulse, early in November, was 75-85 
in the morning and evening respectively. Respira- 
tion 16-17. 

At the close of December the pulse had slowly 
risen to an average, for the two daily observations, 
of 94.1, with, nearly always, a rather faster pulse in 
the mornings ; but, meanwhile, the breathing rose 
to a daily average of 49.4. 

Some of the numbers are remarkable. ' I give in 
a brief column one w T eek, for comparison with 



healthy 


states : 












Pulse. 


Kespiration. 


Pulse. 


Kespiration, 




: 


Morning. 


Morning-. 


Evening. 


Evening. 






10 A.M. 


10 A.M. 


10 P.M. 


10 P.M. 


Dec 


. 22. 


102 


50 


91 


48 


<( 


23. 


100 


52 


99 


53 


u 


24. 


98 


57 


100 


62 


(( 


25. 


90 


55 


87 


47 


a 


26. 


95 


37 


85 


39 


a 


27. 


98 


55 


88 


44 


a 


28. 


93 


49 


88 


89 



Mean 99.3 50.7 91.1 47.2 



200 DISEASES OF THE NERVOUS SYSTEM. 

The respiration was singularly tranquil, despite 
its rapidity, and there was not the slightest appear- 
ance of effort. Digitalis, given in half-ounces of the 
infusion, seemed to have no effect on the pulse after 
some days, but so disturbed the stomach that I was 
forced to give it up. The thirtieth of a grain of sul- 
phate of morphia brought down the breathing one- 
fourth, and the one-twentieth of a grain had a still 
more perceptible effect, so that the average respira- 
tions fell for the last week to 28.1, while the average 
pulse was 81.2. A single full dose of opium, given 
to relieve pain, brought the respiratory rate from 58 
to 17 within a few hours ; the pulse falling at the 
same time from 88 to 73. 

This is a remarkable example of a rather unusual, 
but sometimes overlooked, hysterical symptom. In 
a doubtful case it alone would decide the diagnosis; 
for a like condition, outside of hysteria, is a clinical 
curiosity. 

Nor is this a mere theoretical idea. A few years 
ago I was one of three physicians called to see a lady, 
long ill with a variety of ailments. She had passed 
into a state of stupor, from which, for two days, it 
had been impossible to arouse her. I observed that 
w 7 hile her pulse was about 90, her breathing w y as 
almost imperceptible; on careful count, however, it 
proved to be 96 in the minute, from which I was 
sure that the case would prove, in the end, to be 
hysterical ; an opinion justified within a few hours 
by the repeated occurrence of very violent hystero- 
epilepsy. 

Dr. John H. Brinton and I have reported a very 



VAS0-M0T0R DISORDERS. 201 

remarkable case of rapid respiration in a man. It 
is so rare an illustration that I think it worth while 
to rescue it from the records of the College of Phy- 
sicians and place it here in relation with hysterical 
states of rapid breathing not due, like it, to a 
definite lesion. 

J. W. B., E. Co., 57th Pennsylvania Infantry 
Volunteers, get. 31, shot at Fair Oaks, May 31, 1862, 
by a ball from a sharp-shooter in a tree, at about 80 
to 100 yards distance. The colonel (Campbell), who 
was shot at the same time, and from same source, 
was hit by a conoidal ball, which was removed from 
his arm. It is probable that Barnes was also hit by 
a conoidal ball. The wound of entrance, the patient 
says, was like a clean cut, near the centre of the base 
of the scapula, the direction of the ball was down- 
wards and forwards, and the ball lodged apparently 
behind the cartilage of the 7th or 8th ribs, about two 
inches from the sternum on the right side. 

The patient states that at the time of injury, he 
felt as if he had been " hit hard on the back by a 
stick; he also felt as if he was hurt or torn ante- 
riorly behind the cartilages of ribs of the right side. 
At the moment of injury, there was no shock, but in- 
stantly bloody expectoration, not copious, only two 
or three mouthfuls, dark-red, not bright-red. The 
dyspnoea was great, but he did not faint. In a minute 
or two after being hit, he suffered from nausea, and 
some shock, but there was no vomiting. He did 
not fall. He was not able to lie down, on account 
of dyspnoea, but was able to sit. He rode, sitting on 
the front seat of an ambulance, to Savage's Station, 



202 DISEASES OF THE NERVOUS SYSTEM. 

was there placed on a chair, taken to James River, 
and then on a steamboat to Philadelphia, where he 
Avas carried from the depot to St. Joseph's Hospital 
(fully two or two and a half miles) on a furniture 
car; but during all the time from the day of injury 
to June 16th he did not lie down or leave his chair — 
the same one on which he was placed at Savage's 
Station. Immediately after being hit (within an 
hour), great emphysema from the jaw down to the 
pelvis on right side occurred, for which he was 
bandaged at Savage's Station. 

June 4, 1862, admitted to St. Joseph's Hospital, 
from which he was discharged on the 16th of June, 
the wound having healed. He reentered the hos- 
pital on the 24th of July, and was then treated for 
inflammation of the right pleura, and was discharged 
from the hospital early in December, 1862. Since 
that time, there has been constant pain in the right 
chest, aggravated by exposure. He married in 1862, 
after leaving the hospital in Philadelphia. 

Since December, 1862, he has tried railroading, 
but found the exposure too great. Shopkeeping was 
too confining; could not continue as a street-car con- 
ductor, from inability to speak at times, consequent 
upon spasmodic action of diaphragm. Is now (March, 
1870) the proprietor of a book-stall or newspaper 
stand in the open air. He weighs about 121 pounds, 
having fallen to this from 150 pounds, his former 
weight. 

He has haemoptysis about twice a year, amounting 
to a few small mouthfuls of blood during the day, 



VASOMOTOR DISORDERS. 203 

for two or three days. He has now such an attack. 
Has not had one for six months previously. 

Examination of Chest, — Measurements : Right chest, 
at level of inferior angle of scapula to middle line, 
one inch below right nipple, 11 inches. Corre- 
sponding measurement left side, 10J inches. 

There is pain on pressure, on right side of spine, 
from the 3d to the 6th vertebra, between vertebral 
spine and posterior scapular margin. The wound, 
which is perfectly cicatrized, is on a level with the 
5th vertebra, and about J of an inch from the posterior 
margin of the scapula. Great tenderness over all the 
muscles, between the posterior margin of scapula 
and vertebrae, and up to a point 2J inches above 
cicatrix, and \ below the middle of spine of scapula. 
Hyperesthesia of surface in an area extending from 
1 inch below to 2 inches above scar. 

A very tender spot was detected, 5 inches below 
the posterior angle of the axilla, between the 7th and 
8th ribs. Tenderness was also evident 2 inches in 
front of that point, and extending from the 5th to 
the 8th ribs. 

On the front of the chest, tenderness on pressure 
existed one inch above the right nipple, extending 
to the middle sternal line, and downwards as far 
as the margins of the costal cartilages. The extreme 
of tenderness was marked by a line drawn obliquely 
downwards from the right nipple to about the ante- 
rior margin of the 8th costal cartilage. General 
hyperesthesia of surface existed over this tender 
region. 

The patient experiences pain when he bends his 



204 DISEASES OF THE NERVOUS SYSTEM. 

body forwards; and when he wishes to seize an ob- 
ject on the floor, he crouches, bending both knees 
alike. He himself believes that the ball lies at the 
front and lower part of the right chest, and that it 
shifts w T hen he attempts to laugh or sneeze, or bend 
forwards. 

That some unknown lesion probably exists at the 
point indicated, w T e may readily conceive, and we are 
inclined to think that a sac of false membrane exists 
immediately behind the costal cartilage, and in the 
vicinity of the diaphragm ; and that most probably 
this sac contains the ball ; we think moreover that 
the sac is of some size, and that the ball is loose. 

Anteriorly the inspiratory and expiratory sounds 
were heard throughout both lungs, but they were 
very short and somewhat rough, owing, perhaps, 
to their speed. There was no loss of respiratory 
space at the site of the pain below the right 
nipple, nor w^as there any unusual dulness there- 
abouts. 

Transmitted heart sounds were heard about two 
inches below the right nipple, masking, and to a 
certain extent confusing, the respiratory sounds. 

Percussion over the right lung anteriorly, even 
when practised with the utmost gentleness, produced 
great pain and dyspnoea; especially was this the case 
when percussion was made over the swelling at the 
costal margins, the supposed locality of the ball. 

The upper part of the right lung was clear on per- 
cussion, shading down to the ordinary level of liver 
dulness, and becoming more dull over the costal 
swelling. 



VAS0-M0T0R DISORDERS. 205 

Posteriorly, respiratory sounds were heard over 
botli right and left lungs, more distinctly, perhaps, 
over the left lung. 

Dyspnoea has been present in the case from the 
time of injury. If he laughs heartily, violent dys- 
pnoea amounting almost to suffocation is induced, 
followed by great prostration. 

The marked feature in Barnes's case is the rapid 
respiration. Usually when at rest it is a little slower 
than the heart-beat, sometimes it is almost synchro- 
nous with the latter. On exertion the respiration 
rises rapidly, so as to exceed the heart-pulse in num- 
ber. Thus : 

Feb. 27. — Patient sitting quietly in his own room. 
Pulse 74; respiration 66. 

March 8. — One hour after supper, having walked 
about a mile, he was examined in a standing posture. 
Pulse 90; respiration 76 to 78. Examined in 
recumbent posture. Pulse 78 to 80; respiration 64. 
On the same evening the patient was directed to run 
twice up and down one short flight of stairs. Then 
pulse 100; respiration 108 or 110. 

13/A.— The respiration and cardiac movements 
were synchronous, viz., 78. A little exercise sent 
the pulse to 95 and the respiration to 125. 

l&h. — After a short walk, pulse 100 ; respiration 
120. From the date of the wound until March, 
1863, his breathing was almost thirty times to the 
minute. At that time over-exertion is said to have 
caused the present rapid rate. 

Prior to his being wounded this patient was an 
accomplished diver, and could hold his breath for 

18 



206 DISEASES OF THE NERVOUS SYSTEM. 

over a minute ; now he can hold it only for a few 
seconds. When he does so the heart-pulse becomes 
somewhat slower, a proof of the integrity of the 
pneumogastric nerve. 

The heart does not seem to be injured seriously 
by the long-continued speed of the respiratory 
movements, at least its valves have not suffered, 
although the first sound is often faint, as if there 
were a feeble left ventricle. This would seem likely 
to be the case from the appended sphygmograms, 

Fig. l. 



Tracing of sphygmogram of Barnes's pulse when he is quiet. 

Fig. 2. 



Tracing of sphygmogram of Barnes's pulse when exhausted by exercise. 

taken by Dr. Mitchell, and which indicate a feeble 
heart and a relaxed arterial tension. 

A marked feature in B.'s case is the peculiar 
facial spasm which occurs some fifty or sixty times 
a day. During each one of these spasms the low T er 
jaw is pulled down once or twice, and respiration 
and speech are arrested. Each spasm begins with 
pain over the hypersesthetic space in front. 

The loss of power in the upper extremity of the 
right side is very evident. The patient states that 
immediately after being shot he dropped his gun, 
and that for six months he could not elevate his 
right arm. He states "that the shoulder was 
paralyzed." 



VAS0-M0T0R DISORDERS. 207 

At present he cannot raise the arm above the 
level of the shoulder, and the grasp of the right 
hand is very feeble, contrasting strongly with that 
of the left hand, which is remarkably vigorous for 
one of his build. 

The want of power in the right hand points to the 
probability of its having been due to a reflex paral- 
ysis originating in shock at the time he was wounded. 
Indeed there seems to have been sudden loss of 
power at the moment, and certainly no amount of 
disuse possible to a man who has to do even light 
work will account for the vast disproportion between 
the strength of the two forearms. 

This singular case gave rise to much debate when 
it was shown by us to the Fellows of the College, 
but no satisfactory explanation of its phenomena 
was ever obtained. 



208 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE XII. 

HYSTERICAL APHONIA. 

The patient before us to-day is a very notable illus- 
tration of the pranks which may be played by 
listeria. I read you her history, and as you hear it 
I think you will see that almost at any time a reso- 
lute man, whom she trusted and who understood 
her disorder, could have saved her and her family 
from long years of suffering. Her case will enable 
me to point out to you, as I have done very often 
before, that the natural history of many of the forms 
of hysteria is still an open study. One reason for 
that is, I presume, the disgust with which the gen- 
eral practitioner encounters this malady. It is 
hysteria, and with that seems to end all need for ob- 
servation of details and varieties of symptoms, such 
as more manageable disorders obtain. 

Mrs. B,., aet. 31, from New Jersey, was brought up 
among people of narrow means and larger wants. 
A rather frail constitution and nervous parents 
doubly prepared her for the ills which were, perhaps, 
only hastened by an attack of ague, followed by 
pneumonia, in September, 1870. Soon after recovery 
a day of fatigue and some worries ended in hysterics, 
w 7 ith retention of urine. A more violent fit followed 
an attempt to do some rather hard work. From this 



HYSTERICAL APHONIA. 209 

time the Pandora's box of hysteric ills was opened, 
and they came almost without limit. Remaining in 
bed, fit followed fit, until, when a little better, she 
chanced to smell musk, upon which she fell into a 
state of stupor, and was thought to be dying. Then 
the voice fell to a whisper, and so came and went for 
five years, and at last failed so utterly that for the 
last five years she has uttered no sound. Meanwhile 
she stayed in bed till 1872, and had, in succession, 
general paresis, right arm and hand paralyzed, 
enormous swelling of hand so as to resemble an ab- 
scess, and a variety of hyperesthesias; on one occa- 
sion a blow on the hand caused retraction of the 
head, followed abruptly by recovery of previously 
lost power. Soon afterwards there were in succes- 
sion repeated attacks of hemiplegia, renewed hys- 
terics, paralysis of left leg, and swelling of foot, with 
exquisite hyperesthesia of the whole skin. In Sep- 
tember, 1872, a slight effort brought on palsy of the 
left arm, so that she had finally loss of pow T er in both 
hands, with loss of voice. This was followed by 
anuria, and then by complete absence of saliva, so 
that for a time the mouth was absolutely dry. Mean- 
while speechless, and with paralysis of all her limbs, 
she could only call any one by seizing the handle of 
a small bell in her teeth and shaking her head. 
After a year and a half the use of induction-currents 
seemed to have a good effect, and she was soon able 
to use her hands, and to walk. At this time and for 
seven years the right hand swelled enormously before 
each menstrual flow, and at the close of the week 
the skin came oft" in large patches. In 1876, she 

18* 



210 DISEASES OF THE NERVOUS SYSTEM. 

had violent retro-spasms of the head and motor 
ataxia of the legs. In 1877, she had hysterical con- 
vulsions, photophobia, a variety of pains, glossitis, 
with great swelling of the tongue, long attacks of 
coma, hysterical vomiting, and two w T eeks of nearly 
complete fasting, and spasmodic ptosis. 

You will, I think, agree with me that a more 
miserable catalogue of ills could hardly be made out. 
Within a year the active troubles have faded away, 
and we have before us only a weak, pale, sensitive 
woman, with complete loss of voice. 

You w 7 ill remember that this woman was at my 
last clinic, and that I told her she could probably 
learn to speak. Two days later she w T rote me that, 
for the first time in ten years, she had made a sound, 
and this is all, but in the mean while I asked her to 
come to my house, and there I studied her case yet 
more carefully ; and now to-day she comes back, and 
I shall test the value of the theory I have formed as 
to her case. But, before I do this, let me say a few 
wT>rds as to the types of aphonia and dysphonia con- 
nected with hysteria. You will find in Cohen's 
excellent book, and in Ziemssen, very good accounts 
of this group of disorders, but I think it will admit 
of further study, and I, therefore, venture here to 
tell you about it some things which are not found in 
the text-books. 

Hysterical loss of voice is apt to come on in long 
cases of hysteria without apparent cause. The voice 
goes and comes, is hoarse or feeble, and at last be- 
comes reduced to a whisper, or is lost altogether for 
weeks or years. Then the patient has to write what 



HYSTERICAL APHONIA. 211 

she would have talked ; and if, as in this girl's case, 
her arms be palsied for a time, only manual signs 
remain until the people around her learn to read 
those labial signs with which communication at 
length becomes so easy as to take away desire to 
make the painful effort at audible speech. 

In a few cases emotion causes abrupt loss of speech 
power. Cohen relates such a case; I have seen 
several. Nor when we remember that it is through 
the voice-muscles that we express so many of our 
emotions, can we wonder that it is in the larynx that 
we feel the choking spasm of grief, or that here, also, 
intense sense of pathos, or almost any deep feeling, 
asserts its power by some act of muscular spasm ; or 
that in nervous people yet graver emotional shocks 
result in palsy of the organs through which we are 
prone to express emotion. 

There are, as I have seen them clinically, at least 
three forms of hysteric conditions which disturb 
vocal utterance, and these three forms are sometimes 
all seen in one case, or may exist distinct. We have, 
first, bilateral palsy of the adductors of the vocal 
cords; second, disassociation of the functional activi- 
ties of the various organs needed in phonation; third, 
habitual spasm, or sense of spasm, during use of the 
larynx in speech. 

The first, or bilateral loss or lack of power in the 
crico-arytenoid muscles, is the common type of hys- 
terical aphonia, and is usually found with loss of 
power in some of the other muscles of the larynx. 
If, in a case of hysteria, you have loss of voice, or 
suddenly the patient becomes a whisperer, you may 
be pretty sure that you have to deal with this form 



212 DISEASES OF THE NERVOUS SYSTEM. 

of trouble. Even if there has been a cold and sore 
throat, with cough, you may safety conclude that the 
slight local inflammation did not cause the aphonia, 
but acted as what I may call a hint to the hysterical 
condition. This caution is, I may add, the more 
needed because an outbreak of this form of trouble 
is often caused by catarrh ; but this is the kind of 
thing we see every day in hysteria. -The catarrh 
passes into hysteric paresis. A diarrhoea from over- 
eating becomes a hysterical diarrhoea; an attack of 
true emesis from indigestion is the parent of hys- 
terical regurgitation, and this may last for years. 

Bilateral hysteric palsy of the vocal cords may be 
extreme or slight, but where it is marked you will 
see, with the laryngoscope, that the cords do not 
come well together when the patient makes vowel 
sounds. One cord may come nearer the middle line 
than the other, but neither does its duty. This is an 
easy examination commonly, because, as a rule, hys- 
terical people are not at all disturbed or gagged by 
the mirror ; but this is not always so, and the patient 
we see to-day has a quite sensitive throat. If you 
find a distinct unilateral glottic palsy, you have, 
probably, a non-hysterical paralysis — at least I have 
never seen a monoplegic state of larynx which was 
hysterical. You would naturally suppose that 
aphonia and dysphagia would often be found to- 
gether, but this is rare, very rare, although I can 
recall cases where the two disorders alternated. 

The loss of voice in hysteric aphonia has some odd 
peculiarities, or rather exceptions: the patient cannot 
speak, or can only whisper with mouth or larynx so 



HYSTERICAL APHONIA. 213 

faintly as to be scarcely heard with the aid of the 
ear-trumpet; yet she may be able to sing well, as 
happened in one of Cohen's cases ; or, as chanced in 
that of a lady whom we saw together, she may be 
able to speak aloud in her sleep, and then only. On 
these occasions the unwonted sound of her own voice 
would awaken her, and the disappointment which 
followed the next waking effort at speech was most 
distressing, and the emotion thus occasioned gave 
rise, like all emotion in such cases, to an even greater 
loss of w T hat mere whispering power was left. 

Many examples of these disorders are seen in 
pretty strong, stout, and even ruddy women, and 
when met with in such persons are, like all the hys- 
terical phenomena of the nearly healthy, especially 
unmanageable. When hysteric aphonia is found in 
feeble and easily tired women, the effort to speak or 
cough with an open larynx, or with weak chest 
muscles, gives rise to a good deal of soreness, and 
emphasizes that sense of painful fatigue about the 
pectoral region of which this class of invalids is so 
apt* to complain. The victim of this disease is very 
often able to speak low, the voice breaking at times. 
Other and extreme cases lose the power to whisper 
with the larynx, but can still whisper with the 
mouth; and others, again, are unable to utter the 
faintest sound, or to laugh or cough so as to be heard 
at all. It must be obvious to you that, in the worst 
cases, we have here a dual condition, a paralysis 
which, though without coarse organic cause, may be 
lasting, and a disassociation of the motor activities 
of the respiratory, laryngeal, buccal and oral mus- 



214 DISEASES OF THE NERVOUS SYSTEM. 

cles — parts which, by physiological construction 
and long habit, unite to produce voice. The two 
troubles are often seen together in variable degrees; 
or the incoordination may exist alone, there being 
still power to close the larynx. 

We should then have the second and less well- 
known form of aphonia, and this it is well to study 
with care. The present case is a perfect example. 
If while using the throat mirror, I ask her to sound 
the broad A, the vocal cords come together, but do 
not vibrate, because she is unable to use synchro- 
nously the respiratory muscles to drive air through 
the narrowed orifice. Of course, there is no laryngeal 
whisper. In some of these cases, as I have seen, the 
patient can whistle more or less well, because for 
this act only the mouth and an expiratory effort are 
needed; but there are others who cannot execute 
even this simple act of coordination, and these per- 
sons would seem, therefore, to have also lost power 
to use vocally the lesser bellows — the mouth — in 
connection with the tongue and lips, so that in this 
case buccal whispering would also be lost, and the 
patient would then have what Cohen calls apsithuria, 
and be absolutely whisperless. I will defer speaking 
of the third form of dysphonia until we consider the 
case before us. This young woman has good power 
over the laryngeal muscles. I ask her to speak ; she 
makes a great effort, but, as I found in my a last 
examination, I cannot hear her even with an ear- 
trumpet. She has neither with larynx nor mouth 
capacity to whisper. She can whistle feebly, but 
whistling is not a feminine accomplishment, or she 



HYSTERICAL APHONIA. 215 

might do better. You observe that, when trying to 
speak, she makes extreme movements of the lips, 
and this is done to enable her friends to read this 
language of oral signs which she thus renders clear 
or emphatic. 

What I have here said describes well enough this 
curious condition, which seems not to have been very 
clearly recognized as being sometimes a state apart 
from paralytic conditions. I can give no explana- 
tion of the immediate causes of these singular inco- 
ordinations. Let us now test their presence. It has 
occurred to me that, if I could teach her how once 
more to use with success these disunited activities, 
she might regain her voice. On thinking how I 
could best bring this about, it seemed to me that, if 
I could teach her to speak only with a very full 
chest, I might secure an involuntary success in driv- 
ing air through the larynx. I shall ask her to fill 
her lungs several times, and, when very full, to keep 
her mouth wide open, and, as she sounds or tries to 
sound the broad A, to breathe out violently. I aid 
her by myself performing the act. To her surprise, 
for the first time in ten years, she makes a clear, 
audible sound. Then, always insisting on each single 
letter being made with very full chest, we go over 
the vowels, and then try the labials, and at last words. 
As she leaves me she says, " Thank you." I insist 
that she shall not speak save with a full chest; that 
she must never use oral signs alone ; and that she 
must be silent except during the lessons her sister 
will now give her thrice a day. 

If this had been a case of glottic palsy, I should 



216 DISEASES OF THE NERVOUS SYSTEM. 

think her sudden cure was due to the emotions 
caused by her novel treatment, as Cohen has seen, 
and I also, the mere use of the throat mirror restore 
voice ; but at her first visit here we got no result 
from this or from Oliver's method of manipulating 
the larynx, so that I myself shall believe that the 
result was due to my teaching unused organs the 
easiest way to regain their habitual function. 

Under the use of tonics, rest, and full feeding, 
with vocal lessons, and a continued order not to 
speak at other times, she has continuously improved. 
Whether or not she will relapse depends a good deal 
on her surroundings. Such cases are only too prone 
to fall back. 

Hysterical spasm of the larynx is a phrase which 
I almost hesitate to use, since I cannot be absolutely 
sure that the disorder I shall describe is really due 
to this cause. There are few of us who, at some 
time of our lives, have not known the sensation of 
choking in the throat from emotion. It is a brief 
and unpleasant matter, and for well people a rare 
one, but among highly nervous people, or hysterical 
women, there is a rare form of this trouble, or some- 
thing allied to it, which gives rise to temporary loss 
or inhibition of voice. At first from emotion, wor- 
ries, or without known cause, there is felt in or about 
the larynx a sense of momentary strangling and pain. 
If the person is speaking, the voice breaks, and she 
remains speechless, or the voice becomes shrill and 
then breaks. At every effort there is pain, distress 
referred to the larynx, and squeaky, broken tones. 
There is also a sense of constriction, and sometimes 



HYSTERICAL APHONIA. 217 

the oesophagus seems to share in the annoyance, and 
an upward gulping effort follows or accompanies the 
laryngeal disturbance. I have seen this group of 
symptoms become so frequent in one case, that at 
length the girl refused to speak at all. It was apt in 
this case to follow meals, and these were seasons 
of real suffering, because of the intense dysphagia, 
which caused her to chew every morsel for many 
minutes before venturing upon the task of degluti- 
tion. The meal became, therefore, a severe strain 
upon an already feeble constitution, and this seemed 
to have something to do with the more ready causa- 
tion of the laryngeal disorder at these special seasons. 
A long course of milk and soup diet, inhalations 
of nitrite of amy], and galvanization of the larynx 
finally relieved greatly these troubles, but there was 
no entire cure until a year later I succeeded in 
materially improving her general condition. 

We have, then, laryngeal palsies usually w 7 ith, 
sometimes without, incoordination of the chest, dia- 
phragm, and mouth ; pure incoordination without 
paralysis ; and, lastly, a disease which seems to be a 
temporary spasm of the vocal muscles of the larynx, 
caused by effort at speech — in other words, a func- 
tional spasm. 



19 



218 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE XIII. 

HYSTERICAL JOINTS. 

I do not mean to go fully into the history of dis- 
ordered joints. More than one of the great masters 
in medicine have described them, and I shall not en- 
deavor to better what has been done by Brodie and 
Paget. I judge, however, that the subject has still 
its grave difficulties, because I can recall numerous 
erroneous surgical decisions in regard to these per- 
plexing cases. There is now in the Infirmary for 
Nervous Diseases, a typical example of the malady 
in question. It has been a stumbling block to more 
than one physician, but came hither correctly 
labelled by Dr. Halberstadt, of Pottsville. I will 
state the case briefly, as I desire to show by contrast 
with another how difficult it may be to reach an un- 
troubled conviction as to the diagnosis of certain 
rare examples of joint disorder. 

Here is in brief this girl's story. A fall on the 
knee is followed by pain and a long rest — other falls 
occur with like consequences — finally one results in 
acute hysteria of which Dr. Halberstadt speaks as 
follows : 

"When first I saw Miss B., she complained of in- 
termitting pain in the head, left eye and foot, the 
ears and the left thumb, her eyes were sensitive to 
light, her arms and legs were rigid in extension. 



HYSTERICAL JOINTS. 219 

Heavy sweats kept her bed-clothes wet. Her respi- 
ration was 180, and her pulse so rapid that I could 
not count it. These symptoms I watched for over 
tw r o hours, her mother declaring they had existed 
steadily for five weeks. The whole body moved in 
curious jerks at each inspiration, and her appearance 
was that of being worked by punctual machinery. 
I could detect no disease of the kidneys nor of the 
uterus. 5 ' 

When we saw this girl here a year later, the left 
knee, thigh, and leg were solidly bandaged with 
caoutchouc and flannel. The knee seemed large 
from contrast with the leg above and below, where 
disuse, for she always used crutches, and incessant 
bandaging had caused such atrophy as disuse and 
pressure will bring about. The muscles reacted 
perfectly on both sides, the knee jerk was equal, and 
there was only slight flexion of the knee, and this 
disappeared in sleep and was easily reduced. All 
the graver hysterical signs elsewhere were gone. 
The health was good and all functions in order, 
there was not even the least loss of sensation. 

This was purely a hysterical joint and nothing 
more. Massage and induction-currents were used to 
awaken the unused muscles, bandage and crutch 
were put aside, and after a few words of kindly ad- 
vice she was ordered to walk. In a week she could 
walk five miles, and went home to have, I trust, no 
relapse. 

No case could seem more simple to one accus- 
tomed to see hysteria, but you will be gravely de- 
ceived if you think that it is always made as easy to 
decide as to the origin of lesions of joints. 



220 DISEASES OF THE NERVOUS SYSTEM. 

If there has been but one factor, decision ought 
to be readily reached; but if there has been a real 
injury or true joint disease, and with it hysteria or 
this latter condition primarily, and inflammatory 
joint lesions supervening — you may have problems 
of exasperating perplexity. In the case last men- 
tioned, we had a hysterical history — normal electrical 
reactions, pain without heat or swelling. Let us 
contrast this with that of a patient who was for 
years a too interesting example of joint disease, and 
has puzzled Dr. Shaffer, of New York, and myself 
and others at home and in Europe, for a very long 
time. Her case is one which I may well afford to 
state at length. 

I shall pass briefly over the early history, A girl, 
set. 16, of good tint and fair amount of flesh, came 
to me suffering with hemiplegia of the right side, 
unusual loss of power, analgesia, defective sense of 
touch and of temperature, hysterical emesis, habits 
of eating paper, dysuria, rectal pain, etc. After much 
treatment she became well enough to walk, but for 
some time longer exhibited a perfect type of hys- 
terical ataxia. The sensory losses lessened by de- 
grees, chiefly in that they were not so general over the 
whole side; but a few months after she passed out of 
my care the left leg contracted slightly at the knee, 
and the joint began to be subject to great pain. This 
group of symptoms developed further until the foot 
became extended, the leg bent at a right angle on 
the thigh, and the latter flexed on the pelvis and 
strongly adducted. The knee also became more 
swollen, and all motion was described as agonizing. 



HYSTERICAL JOINTS. 221 

The history of this knee was interesting and worth 
considering, in the light of some of the tests usually 
accepted as of diagnostic value. 

In January, 1882, the leg muscles were as above de- 
scribed. The left knee measured one inch more than 
the right knee. Its contours were decidedly altered 
and it was encased in a brawn-like tissue, especially 
at the back and sides. The patellar reflex was 
nearly alike on the two sides ; there was no ankle 
clonus. The muscles of the left leg were all some- 
what wasted, the calf being an inch less than that of 
the right side. The electrical tests showed only 
quantitative lowering for all currents, and not very 
decisively. The foot was still extended, the heel 
drawn up, and the leg bent on the thigh. 

All day long the joint, unless touched, pressed, or 
handled, remained at about the temperature of its 
fellow, or a half degree below it, but always between 
9 and 9.30 in the evening an interesting change took 
place. The knee became more swollen and the skin 
all over it grew very tense, shining, and of a deep 
red. To touch or shake the part occasionedgreatpain. 
The temperatures were carefully studied by placing 
a surface thermometer, guarded by a grooved cork, 
on the inside of each knee. The right gave always 
very similar readings from day to day, only once 
rising at night to 98° F., and commonly not varying 
much above or below 96.8° to 97.1° F. 

The Table No. V. shows the curious ranges as re- 
gards the left knee, which rose in temperature at 
night from 1 to 4° F. The pulse remained always 
about 80; but between twelve and three all the local 

19* 



222 DISEASES OF THE NERVOUS SYSTEM. 

conditions of heat, redness, swelling, tension, and 
increased pain passed away. The same set of symp- 
toms could be brought about at any time by han- 
dling the knee. Even pressure on the patella was 
followed by an exhibition of like phenomena over a 
smaller area. 

In February, 1884, I saw this lady in consultation 
with Dr. Shaffer, of New York, in that city. We 
found much the same state of things as when the 
joint had been last seen by me. Atrophy from dis- 
use, lessened faradic electrical reactions, reflexes 
entire, and the muscles contracted always, but more 
relaxed when her attention was taken away from 
them. The usual will-lessness, if such a word be 
allowable, was observable in many of her acts, and 
the knees were much as before. 

Dr. Shaffer and I were of opinion that, notwith- 
standing the pain and the remarkable changes in 
the form and size of the knee, there was no evidence 
of any lesions of the joint itself, and that the changes 
mentioned were external to the articulation. It was 
certainly unlike a synovitis, and still more unlike 
articular osteitis, nor did it resemble at all any- 
thing known to the books. I describe, in the next 
lecture, a not altogether dissimilar affection, in 
which it was difficult to say how much was hys- 
terical and how much due to limited organic dis- 
ease of the spinal cord. 

In the present case, some wasting and much con- 
traction preceded the complaints about the knee, 
so that the order in which the symptoms followed 
one another points to the contractions as hysterical, 





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224 DISEASES OF THE NERVOUS SYSTEM. 

and not as due to articular disease, while this might 
also have been inferred from the form of these con- 
tractions, the muscles affected, and the intensity of 
the symptom. Our only doubt would be as to the 
knee. Was that hysterical only, or was there in it 
some coarse organic lesion ? My own decision has 
always led me to class it as purely hysterical, and, 
recalling the local temperatures, the absence of gen- 
eral fever, the peculiar vaso-motor changes, the pres- 
ervation of the knee reflexes, and the fact that the 
electrical reactions were better than the amount of 
wasting would have led us to expect, recalling all 
these, I say it is hard to decide otherwise than for 
hysteria. 

We have had here to deal with a hysterical wo- 
man, a hysterical leg, a hysterical knee-joint, and 
the supervention of changes about it, and, possibly, 
in it, which must be looked upon as new and pecu- 
liar in the pathological history of joints. 

While these pages were in press, I received from 
Prof. Henry Sands, of New York, some facts as 
to the later history of the case. 

Miss went to Europe in June, by advice of 

Dr. Shaffer and myself. In Germany she consulted 
Dr. Bettleheim, who, in his letter of advice, describes 
the knee as swollen with synovial fluid, and states 
that probably the cartilages and ends of the bone 
were thickened. His impression was that there was 
a spinal myelitis on a hysterical foundation. Pro- 
fessors Billroth and Nothnagel considered the case, 
as I do, as a most unusual one, and advised that 
measures be taken to cause ankylosis, believing that 



HYSTERICAL JOINTS. 225 

the patient would thus be made more comfortable, 
and that, of course, the contractions would disap- 
pear. Prof. Billroth seems also to have believed 
that some fungous products would be found in the 
joint. "In accordance with these views," says Dr. 
Sands, " and with much doubt as to the character 
of the disease, and a full sense of the obscurity of 
the case, I laid open the joint freely, using full anti- 
septic precautions, and explored it thoroughly. I 
found the joint surfaces normal, the enlargement 
being due to plastic infiltration of the fatty and con- 
nective tissues, outside the capsule. The thickening 
was due to ordinary inflammatory products, and was 
evidently not tuberculous. The wound was closed 
and the leg put on a straight splint, in the hope 
that ankylosis would result. No inflammation took 
place in the joint, and, as soon as the limb was re- 
leased, the contractions gradually returned. Then 
the leg was placed in a plaster splint, but the patient 
complains incessantly and bitterly of pain in the 
joint, while declaring also that her sufferings have 
been lessened by the operation." 

For those who believe that hysteria never gives 
rise to organic changes this case will certainly be 
full of instruction. 

Of course, cases like this— cases as difficult to un- 
ravel—are rare ; but it is a mistake also to suppose 
or assert that the neuro-mimetic joints, where dis- 
ease is simulated, are always free from swelling, and 
even from redness and heat; but, then, the nature of 
the swelling, the character of the redness, the time of 
the temperature changes, the relative mobility under 



226 DISEASES OF THE NERVOUS SYSTEM. 

ether, and the state of the muscles should in all cases 
make mistakes impossible, except for physicians who 
fail to see sign-posts as plain as these. 

This is not the only case in which I have met 
with high temperatures of a joint at night; usually 
Sir J. Paget's dictum is a safe guide, when he tells 
us that " a joint which is cold by day and hot by 
night is not an inflamed joint — that is certain." 1 

It remains to be said that many hysterical joints 
are associated also with contractions of hysterical 
origin, and which cause enough and sufficiently 
prolonged immobility to give birth to that really 
painful state of a joint so readily caused by too long 
use of a splint. 

It is also worthy of remark that the knee is the 
joint most subject to hysterical disorder, and that the 
smaller articulations are not often complained of. 

1 Clinical Lectures and Essays. See also for the best essay on 
the comparative symptomatology of hysterical and inflamed joints, 
1ST. M. Shaffer, op. cit. 



ORGANIC DISEASE OF THE SPINE. 227 



LECTURE XIV. 

HYSTERIA AND ORGANIC DISEASE OF THE SPINE. 

I have recently been endeavoring to learn from 
my recollections and my note books what share of 
old hysterical cases pass into a condition of organic 
disease of the spine. I can thus recall eleven cases 
of which I have, or have had, knowledge as bed- 
ridden hysteric patients for at least twenty years. 

Five of these presented more or less rigidity and 
contraction of the leg, and in one the contractions 
were extreme. In all of the rigid cases and in twT> 
others there was sensory impairment. I have notes, 
more or less complete, as to the electrical conditions 
in all of the instances of contraction. In three there 
was or is only impairment of response to faradic 
electrical excitation. In two there exist all the 
ordinary defects represented by R. D., or reaction of 
degeneration. These two are probably, I may say, 
surely examples of hysteria which has terminated in 
an alliance with organic disease of the anterior regions 
of the spinal cord. Such cases must, I think, be very 
rare and without an extremely careful examination 
with all the electrical tests, mistakes may readily be 
made, and a verdict of permanent and certain dis- 
ability pronounced over what is still only and purely 
a case of hysterical contraction, and anaesthesia with 



228 DISEASES OF THE NERVOUS SYSTEM. 

the atrophy which comes of disuse and artificial im- 
mobilization. I may go a step further, and say that 
even in some hysterical cases where the full elec- 
trical signs of degenerative change exist supported 
by ample ocular evidence in other directions, we 
may sometimes accomplish more in the way of relief 
than we could expect to do in most cases of spinal 
change apparently as distinct, and where no hysteria 
was involved. I have seen several such cases, and 
one of them I shall presently relate. Because of 
their so complete recovery I have felt a certain hesi- 
tation as to retaining my opinion that grave changes 
in the cord had been a part of their pathology. I 
feel quite sure that no neurologist would have seen 
the case I shall state in justification of my doubts, 
without to some extent sharing them. 

Apart from the diagnostic difficulties there are 
other reasons why T state this case at some length, 
and why I regret that its early history has never 
reached me in as full a shape as I might desire. 

Mary B., set. 19, late a student at a girl's college; 
height 5 feet 6 inches ; weight at her 17th year, 156 
pounds; florid complexion, light colored hair; of 
natural intelligence, ambitious, and studious, but not 
remarked as emotional or morbid. The family his- 
tory is exceptionally good. 

Miss B. had scarlatina at fourteen, followed by 
jaundice and emesis at intervals for a w r eek. In 
1877 she had a like attack of vomiting, without 
pain or jaundice. 

In June, 1880, she was graduated at a high school, 



ORGANIC DISEASE OF THE SPINE. 229 

and in September went to a college for women, where 
she worked very hard. In March, 1881, she returned 
home, very tired, for a brief vacation. Here she had 
a headache of great severity for a day, and was left 
by it rather weak, and disturbed by occasional ver- 
tigo. Resuming her studies with difficulty, at the 
fourth day she once more broke down, and became 
abruptly peevish, irritable, very feeble, and sensitive 
to noises and light. At times her vision became 
blurred, a part of the whole field being lost for a 
time. Meanwhile, for a week, she kept her bed, 
without fever and with fair appetite. 

April 16th, she again went home, sleeping ill, 
and much as above described. 

I am told that upon April 80 she awakened with 
severe nasal catarrh, sore throat, intense headache, 
and what is vaguely spoken of as congestion of the 
liver. The headache was soon better, but vomiting 
set in anew, and on May 2d became persistent and 
inexorable. The region of the liver and epigastrium 
was throughout intensely sore, and the surface of 
the abdomen exquisitely hypersesthetic. From this 
time all food, save twice a little dry toast (an inch or 
two), was refused. I am told that she swallowed 
no food save this until June 16— a fast of forty-five 
days. Water she took in small amounts, but always 
it instantly provoked regurgitation. During this 
time her menstrual flow returned, and then amidst 
a storm of pain and cramps, with general hyperes- 
thesia of skin, ceased, to return no more for months. 

The evidence as to this amazing fast is, as far as I 
can judge, complete. Her mother, a woman of 

20 



230 DISEASES OF THE NERVOUS SYSTEM. 

vigorous character, was the sole nurse, and rarely 
left her. The assisting care was by relatives, and 
was methodical and accurate. The physician who 
watched her case was a very able man. Nor, despite 
my skepticism, have I been able to find fault with 
the evidence. Her own state of exhaustion, the 
vomiting, dry tongue, fever, and cramps, forbade the 
belief in deception as possible, even had she been 
ever left alone for a moment. 

About June 14 the tendency to anuria developed 
into a complete expression of this symptom, followed 
after twenty-four hours of suppression by a scanty 
flow of bloody urine with epithelial and renal casts. 
The exhaustion was now extreme. Her vision 
became doubled, articulation impaired, breathing 
labored, and her memory failed rapidly. Tempera- 
ture 99.5° to 102° F.; pulse 120 to 140. Then food 
was given by enema. 1 A little barley-water was 
retained on the stomach, and there was a general 
betterment until June 26, when the urine was again 
scant and bloody. About this time she became un- 
conscious, the strabismus was more marked, and her 
loss of voice entire. Involuntary escape of urine 
and feces took place. At times there was muttering 
delirium, or else her head cleared a little and her 
voice became distinct only to prove that all memory 
of past events seemed to have been lost. The nausea 
meanwhile ceased, but food was taken only in small 
amounts because of the impaired deglutition. 

1 Before this, in the early stage of the fast, an enema was used, 
but not repeated owing to the convulsion it caused. 



OKGANIC DISEASE OF THE SPINE. 231 

By slow degrees she became better. The bowels 
acted more comfortably, the urine grew clear and 
lost its albumen ; some food was desired, and the 
intervals of sanity were longer and more frequent. 

At this time a new set of symptoms arose. The 
acute expressions of hysteria passed away, and, be- 
coming more and more conscious, she began to 
complain that her legs seemed to be too long and 
were heavy, while quite rapidly both legs drew up, 
bending to an extreme limit at the hip, knee, and 
ankle, but not being also adducted strongly, as are 
usually hysterically contracted legs. This change 
was complete by August 16th, and was accompanied 
with intolerable pains in all the limbs, but especially 
in the feet, which were, however, insensible to touch 
and to the pin-point. Meanwhile her other symptoms 
grew less severe, her eyesight, which had seemed to 
be quite lost, slightly improved, and her appetite, 
digestion, and bowels became more manageable. 
The pulse was still 120 to 180 ; respiration 80 to 40; 
temperature 99° to 100°. Intense surface hyperses- 
thesia existed, and sleep for 2 to 4 hours a day was 
won by the help of morphia and bromides. About 
September 1st her voice returned and became full 
and clear. Eemoval to the country September 5th 
caused further gain, so that the pain lessened in her 
arms. All the nutritive functions grew better, and 
her sleep increased. Unfortunately, this gain soon 
ceased, and the disabilities and suffering of the 
legs became worse and worse, the mind remaining 
feeble and the memory as I have described it. 

She was finally brought to me in a state which 



232 DISEASES OF THE NERVOUS SYSTEM. 

filled me with despair, mingled with regret, that in 
such a condition she should have made so long and 
so useless a journey. 

Indeed, the figure which lay before me on the 
bed was not one to make a doctor hopeful of its 
future. 

When first I saw her the girl was lying in bed on 
her side, with her legs flexed to the utmost, and her 
knees drawn up almost to her chin. Her face was 
ruddy, naturally, and was much flushed, but the 
lips, gums, and conjunctiva were quite too pale. 

The extraordinary dilatation of the pupils at once 
arrested my attention. I never saw so large a pupil- 
lary space. Without warning, I threatened the eyes 
by a rapid motion, and saw that she was blind. She 
could tell night from day, but could do no more. 
The conjunctiva was sensitive. There was no stra- 
bismus, and the eye-grounds were normal. She had 
not menstruated since June. 

Her feet were too numb to distinguish the points 
at any distance, and she felt neither touch nor needle- 
pricks below x the ankles. If I moved the foot she 
felt it, but w r as not always sure as to the limb han- 
dled. Passive motion of the toes was unfelt. Above 
the knees the feeling in all forms was better, and 
w T as nearly normal in the hands. 

Of late the pain in her feet had become atrocious, 
and especially was this so at night, whence her sleep 
was becoming less and less deep, so that often whole 
nights of extreme pain were endured without sleep. 
This pain was an ache of the feet, and more of the 
left foot. Otherwise, except a nearly constant head- 



ORGANIC DISEASE OF THE SPINE. 233 

ache, there was no pain. Passive efforts to straighten 
the legs occasioned unbearable pain. That this was 
not the simple contracture of hysteria was shown 
by the failure of these muscles to relax at all under 
complete anaesthesia. Moreover, about the tendo 
Achillis and in the popliteal spaces in both legs, 
there was a brawny deposit which seemed to be in 
the areola and about the tendons. The feet were 
cold in the day-time, slightly oedematous, and apt to 
be hot and red at night. 

The muscles and nerves of the left leg gave all 
the ordinary reactions of degeneration, those of the 
right side being less complete. The interosteal 
groups of the left foot failed to respond to all excita- 
tions. Above the knees the left thigh muscles, 
anterior groups, showed quantitative diminution of 
reactions. 

Owing to Miss B.'s weakness and to the con- 
tracted state of the limbs, she usually remained on 
her left side or on her back supported by pillows. 
The loss of vision, the vast pupils, the lack of 
memory, and the lessened power to think, combined 
to give to her face a vacant though gentle and 
childish expression. All efforts to raise her even 
to a sitting posture resulted in such violent vertigo 
as to discourage any renewed attempts. 

The knee jerk was absent on the left and lessened 
on the right side. The secretions were normal, and 
the urine free from albumen. 

It seemed to me improbable that all the phe- 
nomena of this sad case could be referable to hys- 
teria. But it also appeared to me impossible out ot 

20* 



234 DISEASES OF THE NERVOUS SYSTEM. 

this complexity of symptoms to select those which 
were essentially due to former uraemia, to possible 
disease of the spine, or to mere functional nervous 
troubles. A careful blood count showed the pres- 
ence of decided anaemic conditions, and accordingly 
lactate of iron was henceforth used steadily in full 
doses. 

The horrible pain in the feet was destroying sleep, 
making sedatives necessary, and seemed to demand 
most attention. For this I ordered alternates of ice 
and heat to the feet thrice a day, massage, and 
faradic electricity, whilst an attempt was made to 
straighten the legs by a Stromeyer splint, which only 
increased the pain, and was abandoned. In a fort- 
night the calf muscles began to respond to the faradic 
battery and the hardness about the knees and ankles 
lessened so decidedly that soon after I determined, 
on consultation with Dr. W. W. Keen, to have the 
tendons cut and to extend the limbs. Accordingly 
on December 5th and 8th, Dr. Keen divided the 
tense tendons at the groin, knee, and ankle in two 
operations, and with unusual difficulty extended the 
limbs upon splints. There was not the least relaxa- 
tion from the fullest use of ether, and so great was 
the force needed to straighten the legs that we 
dreaded lest some rupture of nerve or arter}^ might 
occur. As it was, the skin beneath one knee cracked 
a little despite all our care. Certainly the relief 
thus given was abrupt and nearly complete, so that 
in a day or two after the last section all narcotics 
were laid aside. Whether this grateful change was 
due to extreme stretching of nerves long imprisoned 



ORGANIC DISEASE OF THE SPINE. 235 

in hardened tissues or not, I am unable to say. 
The operation caused in the feet great tingling and 
numbness which soon passed away, and a rapid gain 
in power, feeling, and nutrition followed. 

In a few days she was at times placed on a board, 
and so secured by straps that she could be raised 
inch by inch thrice a day. At first this caused 
vertigo and faintness, and choking sensations, with 
soreness of the long unused feet. Meanwhile gen- 
eral massage, electricity, and frequent feeding were 
kept up. As soon as she could bear to stand, she 
was trained to kneel, and at last to creep sustained 
by a sheet held by the nurse, in the manner already 
described. Then she learned to use crutches, and 
finally the crutch canes. 

Meanwhile her sight came back by degrees, and on 
February 1st she could write a few words and read 
a page of large print. The pupils were no longer 
dilated. She walked quite well on the cane crutches. 
Menstruation returned January 1st, and was hence- 
forward regular, but for three months was preceded 
by slight delusions, as to having heard conversations 
she had not heard, and by great nervousness. On 
February 16th she stood alone without crutches. She 
had during all this time the most remarkable diffi- 
culty in coordinating her movements. The effort to 
redress her lost balance at any moment seemed to 
result in a momentary delay, so that the needed act 
did not occur soon enough, and thus she swayed to 
and fro, but after February 5th did not fall. By de- 
grees her efforts grew to be more effectual, and. her 
nervousness and fits of depression less and less fre- 



236 DISEASES OF THE NERVOUS SYSTEM. 

quent. With her eyes shut she could neither stand 
nor kneel erect, but by practising blindfolded she 
rapidly acquired better power to stand and to kneel 
with open eyes. 

March 2d she walked well on crutches unaided, 
and drove out. March 10th she came to my house. 
I found then no eye-ground lesions, but observed 
with the ophthalmoscope, what often escapes obser- 
vation without it, that she had a slight but constant 
lateral nystagmus. Vision was normal. Her mind 
during all of this time improved steadily, and it w r as 
most interesting to watch the gradual restoration of 
her memory of past events, and of what she had 
learned at school. When she went home, March 
13th, her power to recall recent events was still bad, 
but it also returned within a few months, during 
which her whole progress was rapid, and at last 
restored her to absolutely perfect use of mind and 
body. 

Let us look back over this long statement. This 
young woman, amidst a confusing storm of hys- 
terical symptoms, had contraction of the legs, which 
had lasted but a few months, but which did not yield 
in the least under the most complete anesthetization. 
The muscular interspaces were glued together with 
a brawn-like material, especially back of the knees, 
as I have seen in some cases of general myelitis. 
The electrical reactions were those of degeneration ; 
the reflex arc was broken. There was motor and 
sensory paralysis. It is difficult to escape from the 
conviction that we had here a diseased spinal cord, 
whilst the readiness and the completeness of the 



ORGANIC DISEASE OF THE SPINE. 237 

cure cannot but cast some doubt on this conclu- 
sion. 

This, with some other cases which I may detail 
in future, has led me to the belief that organic 
maladies occurring in profoundly hysterical people 
do not always present exactly the same types as exist 
in patients not hysterical. Otherwise how shall we 
account for the remarkable cure of this case, and for 
the utter disappearance of all of those evidences of 
local myelitis which we usually regard as ending for 
the patient all hope of an active life ? The clinical 
history of acute disease in hysteria is yet to be 
written ; but even were it completed, such cases as 
I have given must continue to puzzle us until we 
know more — and we now know nothing of what 
constitutes the physical basis of the disorder w T e call 
hysteria. 



238 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE XV. 

GASTROINTESTINAL DISORDERS OE HYSTERIA. 

I have said in these lectures very little as to the 
gravest of hysterical symptoms — the persistent hys- 
tero-epilepsies, and the multiple and severe contrac- 
tions which Charcot and others describe. I have said 
little because, in my experience, and it has been very 
great, these terrible cases are rare in America in any 
class of life, and most uncommon in the lower classes, 
among which Charcot seems to have found his worst 
and most interesting cases. In this disorder, as in 
chorea and many other diseases, there is, I suspect, 
some difference between this country and Europe. 

My own clinic furnishes yearly hundreds of cases 
of neural maladies, but while I often see examples of 
every type of the milder forms of hysteria, it is ex- 
tremely uncommon to encounter the more severe 
and lasting forms of the disease. 

My friend, Dr. C. K. Mills, who has charge of the 
extensive out-wards for incurables at the Philadel- 
phia Hospital, writes me that his experience is simi- 
lar to mine. He says : " My wards contain some 
cases of hysteria of long duration, but they are not 
numerous. As the result of some experience, both 
in and out of hospitals, I have come to the conclusion 
that cases of grave hysteria, such as the hystero-epi- 



GASTRO-ITSTTESTINAL DISORDERS. 239 

lepsies of Charcot, are rare in this city and country. 
Spasmodic disorders, associated with hysteria, do not 
seem to me to be as frequent here as abroad. Hys- 
terical palsies are more often met with. Neuralgia, 
spinal irritation, ovarian hypera-sthesia, and special 
forms of mental and moral perversion are, in my 
experience, the more usual forms of American hys- 
teria." It is impossible to acquire as to a matter like 
this precise statistical information, but from what I 
know of the experience of other physicians in New 
York, Boston, Baltimore, and Chicago, there is every 
reason to believe that it does not differ from the 
views entertained by Dr. Mills and myself. The 
causes of this difference in the symptom-products of 
a disease so common, and which finds in all lands 
and all female human nature enough conditions 
favorable to its growth, would be a somewhat inter- 
esting inquiry, but one for which I must confess there 
is yet wanting satisfactory material. 

I have given in the final lecture of this volume 
some general directions as to the treatment of ex- 
treme cases of malnutrition and hysteria. I would 
like to make here some remarks as to the especial 
difficulties which meet us in connection with the 
stomach and bowels of hysterical women. No 
matter whether we treat them, as is preferable, by 
exercise and baths and change of air and tonics, or 
are driven in despair to the more unnatural treat- 
ment by seclusion and rest, we have still in all cases 
to feed them, and in all to see that the bowels are 
kept reasonably open. The lighter cases of hysteria 
which come afoot to my clinic can give you no idea 



240 DISEASES OF THE NERVOUS SYSTEM. 

of the gigantic, almost grotesque, proportions which 
symptoms may assume in the graver cases of hys- 
teria, but in each and all it is usually some trick 
of the stomach or gastro-intestinal tract which soon 
or late baffles or perplexes us. In one case you 
have an apparent inability to chew; food rests in 
the mouth until helplessly removed by a nurse or is 
half passively let fall out by the patient. I have 
such a case now. I had to begin by admitting an 
interest in her failures and advising her to move the 
jaw with the hands, which she did do for a while 
until the power or the belief in the power to chew 
came back. 

Next comes the oesophagus with its troubles — at 
times a spasm, at times a paralytic state, more rarely 
a pharyngeal anaesthesia — but in each case attention 
to the act of swallowing helps to embarrass it. 
This difficulty may come on abruptly and be for a 
time the only notable hysterical symptom. The 
most common form of pharyngeal trouble is dis- 
ability to swallow solid food. The patient's throat 
behaves to every solid 6v semi-solid morsel as in 
many w T ell people the throat does to a pill. The 
contact seems to irritate the mucous surface unduly, 
and in place of the usual normal muscular reflex, 
there is a mutinous response on the part of the 
pharynx, and, as the patient tells you, the morsel 
will not go down. There are other people whose 
food meets with no difficulty in the pharynx, but 
encounters below this region muscular spasm, which 
drives it up again, either quietly or with violence, 
and sometimes this trouble is only encountered at 



GASTRO-INTESTINAL DISORDERS. 241 

the lowest part of the oesophagus. These forms of 
dysphagia— these varieties of oesophageal regurgita- 
tion — are apt enough, soon or late, to involve the 
stomach in a similar habit. 

Gagging is a symptom with protective values at 
times, and, like voice failure, is so near to a normal 
product of emotion that its exaggeration in the 
nervous is not to be wondered at. In such persons 
it may be readily fostered into a troublesome habit. 
I have seen several cases in lads and some in men. 
In one instance, every novel social effort or expe- 
rience causes regurgitation or diarrhoea, or both, so 
that life has become a burden to the victim of this 
curious neurosis. 

You will be well off if you escape these exasper- 
ating disorders in your early hysterical cases. They 
are apt to be enduring and difficult of relief. I think 
it curious that dysphagia should be so rare in old 
hysteric cases. There are symptoms which are rela- 
tively common early in cases, others which are seen 
later, and are apt to last. Dysphagia one sees very 
often in cases which are afoot. 

If we fail of this annoyance, we may have to meet 
certain gastric disorders. One is loss of appetite, 
anorexia; the other is vomiting. Of this latter 
symptom I have already said something in a former 
lecture. What I now refer to is the simple regurgi- 
tation which we meet with in these cases. There is 
no nausea — certainly after a while none — but the 
food is returned to the outer air with a gulp, and 
often with remarkable and painless ease. 

You may think this sounds like a rather mild 

21 



242 DISEASES OF THE NERVOUS SYSTEM. 

malady ; but in reality it is one of the symptoms 
which, while it may haunt any stage of hysteria, is 
of all symptoms except multiple contractions the 
most enduring. I can recall a number of bed-ridden 
cases of hysteria which have lasted from fifteen to 
twenty-five years, and which are in the habit of 
vomiting every meal ; and have done this for years. 
One has actually grown stout under this ; but she is 
an opium-taker, and rest with opium greatly aids the 
storing up of unwholesome fat. The others are at 
least not greatly wasted, and you ask yourself in vain 
how they live upon the small quantity of food they 
seem to retain. 

We are apt, however, to forget how small is the 
amount on which a person can live if at entire rest 
a-bed. Then, also, the act of regurgitation is not 
immediate upon the entry of food to the stomach; 
nor, as 1 know from careful inspections, do these in- 
valids vomit more than a part of what they swallow. 

I put aside for the time the symptom loss of appe- 
tite, because of all of the minor hysterical embar- 
rassments we meet with, this is the worst. 1 To call 
this loss of appetite, anorexia, but feebly characterizes 
the symptom. It is rather an annihilation of appe- 
tite, a lack so complete that it seems in some cases 
impossible ever to eat again. Out of it grows an 
antagonism to food, which results at last and in its 
worst forms in spasms on the approach of food, and 
thus in turn gives rise to some of those remarkable 
cases of survival for long periods without food, which 

1 Sir Wm. Gull. Trans. Clin. Soc. vol. vii. p. 22. 



GASTRO-INTESTINAL DISORDERS. 243 

you need not confound with the more or less suc- 
cessful efforts to deceive by the pretence of fasting. 
You will have constantly to deal with the various 
grades of this disorder, if you are called upon to 
treat hysteria. "When it is merely failure of appe- 
tite, you may disregard it as you would the anorexia 
of fever, no matter how extreme it may be, and in- 
deed the more so because it is extreme. There are 
some useful hints w 7 hich you may keep in mind for 
these contingencies. Fluids can be taken when 
solids are inhibited by the disgust they cause, but, 
as regards solids themselves, if they be finely divided 
or put in a fluid as mincemeat in soup or rice in 
milk, they are sometimes taken well, whilst if alone 
they would be rejected. I may also add that if the 
patient be in bed you will often be able to give 
solids, if the nurse herself feeds the patient, since 
then you get rid of at least one volitional act, and 
the added chance for deliberation, and consequent 
disgust which it affords ; nor is it wise to delay rectal 
feeding, as it is apt to be delayed. 

Sometimes this symptom exists only at the men- 
strual period, or is then greatly intensified, and, as 
at this time the consequences due to loss of blood 
are in feeble women made worse by failure to eat, 
one of the most valuable lessons you can teach such 
women is the absolute need to eat, or, at least, to 
drink nutritive food, whether it be agreeable or not. 
The graver cases of self-starvation which arise out 
of the superlative degree of hysterical dislike of food 
are far more serious. They result, as I have said, 
in the patient refusing all food, and sometimes before 



244 DISEASES OF THE NERVOUS SYSTEM. 

such cases the utmost skill and the largest experience 
are simply impotent. Few of these cases exist with- 
out there being a certain amount of doubt as to 
whether or not the supposed fasts thus brought 
about are really fasts, yet, as regards some of them, 
there can, I think, be no doubt. 1 

I have seen several instances of excessive fasting, 
and I propose now, in addition to that already inci- 
dentally described, to call your attention to two 
others which possess peculiar interest. The first 
one I studied with extreme care and with every pos- 
sible advantage; the second came to me long after 
the time of fasting had passed, and although a 
woman to all appearances hopelessly hysterical, 
completely recovered. Her fast was observed by 
physicians as competent as Charcot and Brown- 
Sequard, and of it I have a very good history : 

Miss L. C, set. now 38 years, had in her 18th year 
an unhappy love affair, and soon afterwards a fall in 
which she struck her back. Within a few weeks 
intense spinal irritation set in, for which braces and 
corsets were used, and, these failing, rest in bed was 
prescribed. The latter remedy was a fatal one, and 
she has never since left the bed to which a physi- 
cian's orders sent her. It were tedious and useless 
to dwell on the wild variety of symptoms which fol- 
lowed, as we are dealing now with only one of them. 
Hysterical paralyses, anaesthesias, ischuria, anuria, 
polyuria, hyperesthesias of skin, eyes, and ears, suc- 
ceeded one another singly or in perplexing groups. 

1 See case in the last lecture. 



GASTKO-INTESTINAL DISORDEKS. 245 

A year or more before I first saw her, contractions 
of the two legs and feet began, and went on from 
bad to worse ; while both legs to the waist were in- 
sensible to pain and changing temperatures, but still 
appreciated the position of a touch quite fairly well. 
The body was excessively wasted, the skin dry and 
sallow, and covered with bran-like scales of epithe- 
lium. About the sixth year of her disorder she 
began to have a constipation so obstinate that neither 
drugs nor mechanical aid was of the slightest use, 
and from this time for years the bowels were moved 
but once a month, at which time there were violent 
attacks of hystero-epilepsy. At or near the time 
when this difficulty developed itself fully, she ceased 
to pass water more than once a day. With the help 
of careful nurses, I was able to study this curious 
symptom which in her assumed an unusual form. 
During thirty-nine days her urine reached a daily 
average of three ounces. The specific gravity was 
1040 to 1060. It was dark, and clouded with urates 
and crystals of oxalates and uric acid. The pulse 
rose to 120 ; the respirations to 60 or 70 ; and in 
place of the usual vomiting, which Charcot has 
studied so admirably, and which he has shown to be 
vicarious and charged with urea, profuse sweats 
broke out, and left the skin covered with a white 
film in which I found large quantities of urea. Then 
the scene changed, and about the thirty-ninth day 
the sweats ceased, violent vomiting with nausea fol- 
lowed, and she began to drink vast quantities of 
water, which seemed to be absorbed with great 
speed, since the vomiting which took place at inter- 

21* 



246 DISEASES OF THE NERVOUS SYSTEM. 

vals was merely of a thick, slimy mucus. At the 
same time the anuria ceased, and, from passing some 
days no urine at all, she poured forth large amounts 
of limpid water, sp. gr. 1005 to 1012. 

The fluid thus secreted averaged, for ten days, five 
to ten quarts ; but the amount swallowed was equal 
or more in amount. By degrees this symptom faded 
away, and she drank less and less, and ate almost 
nothing; until, at the close of another month, the 
urine growing smaller in quantity, she ceased to 
vomit, except when urged to take food. Her condi- 
tion was then as follows : She passed six to ten 
ounces of urine daily, and drank, by the teaspoon, 
about twelve to fourteen ounces of water. She took 
no food at all for ten days, and then but a few tea- 
spoonfuls of milk, which always caused vomiting. 
From this time twenty days passed, during which 
she took no food, but had fifty to eighty drops of 
laudanum daily, which she never vomited. Her eyes 
remained closed, the least vibration or light caused 
agonizing cries, and every one expected to see her 
die at any moment. Efforts at rectal feeding or in- 
unction of oils gave rise to horrible spasms, and in 
this condition day after day went by. The watch 
over her was rigid and faithful, and every effort even 
to give a teaspoonful of fluid was carefully noted. I 
am as sure as I can be of anything that in one month 
and five days she never took in all more than twenty- 
four ounces of milk, and the amount of water I have 
mentioned. Whether this almost incredible absti- 
nence was aided by the large quantity of opium 
taken is, at least, difficult to say. There were, 



GASTRO-INTESTINAL DISORDERS. 247 

during the time in question, a large number of hys- 
terical spasms, but, with this exception, the patient 
lay almost motionless. Now, as yet, w r e quite lack 
material for the determination of the nutritive needs 
of a body at absolute rest ; so that it is hard to decide 
how much is needed for the mere sustenance of neces- 
sary function. I have seen a woman, weighing one 
hundred pounds, remain at rest in bed, and lose no 
weight in ten days on a diet of one pint of good milk 
daily. 

Certainly my patient lost weight. At the close of 
her fast, when she began to take and retain milk in 
small portions, she was wasted almost to the last 
degree, and this has never failed to happen in such 
experiences as I have had of true fasting. This 
woman had in all three periods of abstinence, but 
the one I have described was by far the longest. 
The contractions have of late years become more 
and more extreme, and, as they have increased, the 
anesthesia has become less, while the electro-mus- 
cular excitability of the leg-muscles has lessened. 
I have little doubt that the lateral columns of the 
cord are now in a state of advanced sclerosis. 

The second case of fasting was also one of extreme 
interest, because abstinence was one of the series of 
most interesting phenomena, covering some years ; 
and resulting, finally, in a nearly complete restora- 
tion to health. 

Miss L., of Connecticut, set. now 28 years, went 
abroad after having suffered a long and severe 
strain on her emotions a,nd sympathies; a strain 
which did not lessen, but from which she fled in de- 



248 DISEASES OF THE NERVOUS SYSTEM. 

spair. The results were broken sleep, great, though 
suppressed, nervousness, but no notable functional 
disturbances. To keep down this sensation of 
nervous excitement she was accustomed to walk 
for hours, returning home with increasing pain and 
tenderness of the spine, the back of the head, and 
the scalp in general. The symptoms were thought 
grave, and were at last treated by a long blister over 
the spine. On removal of the blister there was a 
furious outbreak of weeping, general convulsions, 
and incessant local spasms of the extremities, which 
nothing checked or lessened. These conditions 
lasted during February and March, and were made 
worse by a large crop of carbuncular boils, which 
formed on the part where the blister had been 
placed. About this time, despite the sagacious care 
of excellent physicians, she began to eat less and 
less, and at last, early in April, ceased to eat at all. 
Exaggerated hiccough set in, furious convulsions 
arose at every effort to feed her, and these symptoms 
repeated themselves six or seven times a day, some- 
times without any apparent cause. Rectal feeding 
was given up, because it also gave rise to spasms, 
and there seemed nothing to do but to wait. For 
twenty-seven days neither liquid nor solid was 
swallowed. The tongue became black and dry, and 
cracked; the lips were thin, and crusted like the 
teeth with sordes and blood; the breath foul; the 
eye sunken; respiration quick and labored; the 
pulse 120 to 130 ; and speech whispered and diffi- 
cult. Meanwhile, all convulsive acts ceased, and 
her mind seemed at times quite clear and capable. 



G-ASTRO-INTESTINAL DISORDERS. 249 

Twice her physicians were called in to see her die; 
but the stupor, which seemed almost as deep as 
death, also, in its turn, passed away. 

I am unable to give details as to the state of the 
secretions during all of this long fast. The bowels 
were, I think, moved once, and the urine ceased to 
be secreted after the eighteenth day. 

There was some difference of sentiment in the 
consultation brought about by this grave condition, 
one great authority advising inaction until nature 
asked for food, which he thought would happen. 
Another physician, who was then consulted, saw in 
her case an example of starvation which, having 
reached the line of great peril, demanded forced 
feeding by the stomach tube. I am positively in- 
formed that of this counsel, which it was resolved 
to follow, the patient knew nothing. However, at 
this critical moment she motioned to her physician, 
and in a whisper said she could now take food. 
Then came two weeks of careful spoon-feeding, 
with constant threats of repeating the old troubles, 
when, suddenly, a general tremor set in, and the 
motion growing larger, became twitching, and so 
by a crescendo movement went on into violent con- 
vulsive acts, until, despite the care of those about 
her, she was thrown by a series of spasms from the 
bed to the floor, where she lay, muffled with shawls, 
cloaks, and pillows, to save her from bruising her- 
self. At length chloroform brought quiet. The 
summer wore away with a variety of symptoms, 
such as partial palsies, aphonia, and mental depres- 
sion. The next autumn she was removed to Liver- 



250 DISEASES OF THE NERVOUS SYSTEM. 

pool, and there during the winter she had variable 
degrees of anorexia, and the usual miserable variety- 
of hysterical disorders. Treatment was varied 
enough, but always unavailing, because no treat- 
ment could ignore food, and that was kept at the 
minimum on which existence is possible. Early in 
the next September the girl mustered courage to 
cross the Atlantic, and arrived in New York, suffer- 
ing with a loud, incessant cough, which brought up 
strange quantities of glairy mucus. Emaciated to 
the last degree, with evening fever and morning 
chills, she seemed on the verge of death, when 
almost suddenly the cough ceased, and the starva- 
tion symptoms reappeared, but not in so disastrous 
a shape as had marked their appearance in Paris. 
After a partially successful treatment at the hands 
of her physician in New York, circumstances re- 
moved her from his care. Again the stomach tube 
was advised and declined by the family, and again 
days passed without food, while the convulsions, the 
wasting, the black tongue, the breath, which Brown- 
Sequard had described as an odor like that of altered 
fusel oil, and the shrunken belly, all promised a new 
period of three weeks' fasting. It proved, however, 
less complete than before, and she gradually rallied. 
From this time she remained in bed for nine months, 
eating little and irregularly, a wretched invalid, not 
very thin, but not fat, with occasional spasms, great 
nervousness, distressed by light, by sounds, by any 
company which was not quite agreeable, forever 
alarming her friends by threatening^ of a repetition 
of her former troubles. I somewhat reluctantly 



GASTRO-INTESTINAL DISORDERS. 251 

took charge of this lady early in the following 
spring. The most absolute seclusion and the use 
of skimmed-milk diet, aided by massage, slowly 
triumphed over her disorder, and by and by she 
regained control over her too emotional tendencies, 
and was restored to a state of health unknown to 
her for years. 



252 DISEASES OF THE NERVOUS SYSTEM. 



LECTURE XVI. 

THE RECTUM AND DEFECATION IN HYSTERIA. 

You will find among hysterical and also among 
merely feeble people several forms of difficulty asso- 
ciated with the function of defecation. One which 
is not uncommon is a feeling of great weakness 
after every movement of the bowels. This some- 
times goes so far that the patient will show clearly 
enough, in the pallor and the hastened heart, how 
real is the sudden enfeeblement thus produced. In 
still less common cases the patient faints after the 
stool is passed, and is especially apt to do so if the 
evacuation be loose and therefore sudden. I know 
of one man in quite fair health who is never without 
a sense of faintness at and after a passage, while a 
stool at all watery is sure to cause him to faint. 

Naturally enough, such phenomena are frequent 
in the class of cases we are now considering — so 
that it is sometimes needful to give a little stimulus 
before the evacuation occurs, and also to insist on 
the use of a bed-pan. If you can thus break up a 
morbid habit, or at least make this occurrence of 
faintness unlikety for awhile, the gradual return to 
full health, which, meanwhile, you are in other 
ways promoting, will take care of the future. 

There are other and more formidable expressions 



RECTUM AND DEFECATION IN HYSTERIA. 253 

of hysteria in connection with the intestinal func- 
tions. I bring before you to-day a case which typi- 
cally represents one of these difficulties. 

The patient, a young married woman, aged 29 ; 
has had two children. She ascribes her present 
troubles to the pressure of a retroverted womb on 
the rectum since the birth of her last infant. She 
has worn many pessaries, and undoubtedly once did 
have retroversion of the uterus. To-day she has a 
slightly eroded os uteri, normal menstruation, and, 
if any displacement, a womb slightly anteverted. 

Unhappily she has been told that the womb press- 
ing on the rectum interferes with the downward 
passage of the feces. It once, as she explains, 
caused constipation, but now, owing to the long 
continuance of the malposition, it causes " irrita- 
tion," in consequence of which she has the disorder 
out of which I shall make a text for this lesson. 

She says she has diarrhoea, and tells me that be- 
fore and during her menstrual flow she has six to 
twenty operations a day. This is quite true, and 
for a short time I accepted as correct the idea that 
she had diarrhoea, for when any one says she has 
twenty movements daily we are too apt, as a rule, 
to think of them at once as being necessarily loose. 
But on further study of her case, I soon learned that 
the single stools were never other than very small 
and quite natural or constipated. The moderate 
amount of fecal matter which commonly rests quiet 
in the bowel until accumulation stimulates the in- 
testines to action, in her at once caused enough 
excitation to give rise to a discharge. As this went 

22 



254 DISEASES OF THE NERVOUS SYSTEM. 

on all day, and even at night, it seemed, at times, 
and especially towards bed-time, to give rise to irri- 
tated states of the mucous membrane, so that there 
was sometimes pain and a discharge of shreds of 
mucus, as to which much was said by the patient, 
who carefully examined every passage. 

This was a perfectly typical example of the ex- 
citable rectum due to hysteria, and precisely like 
the irritable bladder which we find in similar cases, 
and which is so exasperating a symptom, or, again, 
like the emesis of hysteria, or the hysterical cough. 

This form of rectal trouble is not very uncommon. 
I have seen it thrice this winter ; but then it is to 
be remembered that I see much hysteria. I may 
recall, in passing, that I have encountered the same 
form of trouble in men. The present case has been 
carefully studied, and I am able to exclude all possi- 
bility of any organic trouble. On the other hand, 
she has had several times rigidity of all the limbs 
during certain attacks which she calls distresses in 
the head and spine, and assures me are not painful. 
In fact, she has the face, the ways, and the habits, 
and even the vagueness, of some hysterical women, 
so that when she describes this rectal disorder I at 
once recognize it as a familiar puzzle of well-known 
parentage. 

You may see the excitable rectum as a mild symp- 
tom at the menstrual time, or brought on by emotion, 
or you may observe it in horribly exaggerated forms, 
so that it becomes the dominant feature of the case, 
or it may be disagreeably associated with a like state 
of the bladder. 



RECTUM AND DEFECATION IN HYSTERIA. 255 

I recall one relentless case of this double disorder 
which had suffered with the " fearful joy" of hys- 
teria under the examinations of I cannot tell how 
many surgeons — English, French, and American. 
This young person had had a disappointment in a 
love affair, five years before I saw her. It caused 
hysterical anorexia, and at last stomachal regurgi- 
tation, which got well a year before she came back 
to America, and while at St. Moritz. Then, by 
degrees, without known cause, arose an irritation of 
the rectum and the bladder, which had become ex- 
treme when she consulted me. She was rosy, well 
nourished, ate well, walked well, and slept between 
the times of discharges. These were said by her 
to occur at least every half hour, as concerned the 
rectum. Each time there were merely one or two 
small scybala expelled, as she said, with violence. 
Her nurse believed that the discharges took place 
at least every hour, and that the bladder was dis- 
turbed almost incessantly, certainly thirty to fifty 
times a day. Nevertheless the rectum was healthy, 
the bladder normal, the urine ideally wholesome, 
and the young person affected, delightfully in- 
terested in my study of her case. 

I have known the irritation of rectum to go so far 
as that the victim wore a bandage and towel, insist- 
ing that at any moment she might be surprised by a 
passage. The successful treatment of such cases is 
sometimes easy, sometimes very difficult. If the suf- 
ferer be really ill, and has to be treated for some form 
of malnutrition, you may be so fortunate as to see the 
irritable rectum getting well as the other symptoms 



256 DISEASES OF THE NERVOUS SYSTEM. 

of hysteria fade away. But suppose you find the 
patient better in all ways but this one, or that this 
annoyance is the single sign of a condition not other- 
wise notable, what can be done to relieve it ? 

If the patient be intelligent, you should first try 
to make plain to her that her disorder is a habit, and 
not a disease; that it arose on slight provocation, 
was yielded to, and so at last became despotic. Con- 
vince her that she can again remake the habit of 
infrequent discharges, and then, if she be resolute 
and will obstinately fight the symptoms, she ought 
to get well. She may be assisted for a time by 
occasional aperients, and better by a daily and com- 
plete washing out of the bowel with an enema of 
water, so as to remove as completely as possible, all 
the feces; but explain to her that this is merely a help, 
and that her own will is the only permanent and 
efficient aid to which she can look. In cases where 
the symptom was temporary or of recent birth, I 
have used opium in suppositories, but not in others, 
nor is it necessary or, as a rule, desirable. In sharp 
contrast with the too irritable rectum, prone to re- 
sent the presence of the smallest amount of fecal 
matter, is the still more annoying condition of 
deficient activity sometimes to be met with. 

The paretic or the paralyzed rectum, for its inert- 
ness becomes that of a local palsy in some cases, is a 
symptom once met at its worst never to be forgotten. 

At some time in the progress of a case of grave 
hysteria we are apt to have to deal with it. The 
upper intestines do not usually share in the difficulty, 
andjhis is a very interesting fact. However we may 



RECTUM AND DEFECATION IN HYSTERIA. 257 

explain it, the food does not come away undigested 
or half digested. The accumulation is that of fecal 
matter fully formed and resting either in the whole 
lower half of the descending colon all the way to 
the anus, or else is merely a collection in the sigmoid 
flexure. For some reason the feces fill up more or 
less of the intestine, and there remain. The diffi- 
culty arises from one of three causes, and sometimes 
from a combination of all in varying degrees. First 
a woman disposed to humor her symptoms and 
make the most of them, becomes, from some cause, 
costive, and ceasing to make any effort to be moved 
at an habitual time, resorts to enemata in increas- 
ing amounts, so as needlessly to dilate and thus 
to weaken the bowel. Aided by the want of will, 
and made worse by inattention, or by the desire to 
exaggerate and foster a symptom thought of moment 
by others, the evil grows from bad to worse, until 
she gets a fissure or hemorrhoids, when the pain 
caused by costive movements adds its inhibitory 
influence. In all of this there is nothing essentially 
hysterical, yet, nevertheless, neglect of the function, 
excessive use of enemata and of purges, are apt to 
occur in the hysterical. Once the habit of inaction 
is made, and has drawn attention, or pain from 
fissure is superadded, we are apt to have the dis- 
order assuming graver forms, and it may be sus- 
pected that sometimes in severe cases in women of 
hysterical type, distinct sensory or motor losses are 
superadded. Such women get curious notions about 
the cause of their constipation. Among these it is 
not unusual to hear that the rectum has formed a 

22* 



258 DISEASES OF THE NERVOUS SYSTEM. 

pouch in front, and that some manual support is 
needed to prevent its increase and to assist the act 
of extrusion. The graver forms of constipation in 
hysteria are due to 

A sensory paralysis of the rectum. 

A loss of power in the rectal muscular walls. 

A want of coordination of the various muscles 
used in defecation. 

A combination of two or of all of these factors. 

In a few cases the rectum and the skin about the 
sphincter are insensible, and do not feel a touch or 
distinguish cold from heat, or exhibit any irrita- 
bility in response to the increasing volume of accu- 
mulating feces. The extent to which, under these 
circumstances, when at their worst, filling up of the 
bowel with feces can go, is something strange. I 
still see, at intervals, a lady for many years a hys- 
terical bedridden case, with contraction and atrophy 
of the legs, who exhibits this difficulty in its most 
remarkable form. For many years she has had the 
bowels moved but once in four weeks. As the time 
approaches the abdomen swells and becomes tender, 
the large daily dose of opium is doubled, and at last 
she takes four ounces of castor oil. As this reaches 
the colon she is seized with violent pains, and me- 
chanical means have to be used to dig out the lowest 
of the feces, and then, amidst repeated use of ether 
and of morphia, and with horrible hystero-epileptic 
attacks, enormous masses of dry fecal matter and 
quantities of mucus are expelled. Although me- 
chanical aid is given with unusual care, and enemata 
of oil and flaxseed abundantly employed, she is apt 



RECTUM AND DEFECATION IN HYSTERIA. 259 

to have the rectal opening badly torn, whilst the 
extreme and rigid flexion of her thighs and knees, 
and the spasm of the adductors, add to the difficulties 
of helping her, and assist to increase her torment. 
There is now no anaesthesia and no analgesia. The 
earlier paresis of the bowels must be referred to a 
date long past when there was remarkable general 
anaesthesia extending to the rectum and vagina, and 
extreme indisposition to have movements of the 
bowels because they were always accompanied with 
a general convulsion. Hence arose by degrees, a 
habit which has been cultivated to the horrible 
extent I have described. 

Paralysis of the rectum is rather rare in hysteria, 
even in bad examples of paraplegia, but sometimes 
it is seen almost alone as a symptom. In extreme 
cases the rectum seems almost absolutely incapable 
of being called into action by feces or enemata. A 
hand may be carried with ease through the relaxed 
sphincter and into the rectum, which yields readily, 
all the accumulation being, as a rule, higher up. 
These manoeuvres may or may not give pain ; at 
the same time the battery has power to move the 
fibres of the intestine and to act on the sphincter. 
In one case this muscle was so flaccid that after a 
passage the anus remained wide open for several 
hours, as I have seen it in complete spinal palsy from 
a rifle-shot. 

In the two cases now in my mind there was no 
loss of any of the ordinary forms of sensation. 
About the anus or within the intestine heat, cold, 
touch, and pain were duly felt, but no amount of 



260 DISEASES OF THE NERVOUS SYSTEM. 

stretching of the sphincter or intestine hurt the 
patient. Yet freedom from pain is not the constant 
rule in these accumulations, and, as in the case I 
shall now relate, competent efforts to arouse to action 
the inert mechanism used in defecation seem to be 
a cause of horrible suffering. 

If it happens to you, in an evil hour, to have one 
of these cases to treat, with the additional need to 
treat also the difficulties with which some tender 
mother surrounds such a case, j r ou are much to be 
pitied. T recall such an example, which I saw in 
consultation some years ago. It began with a spot 
of abdominal tenderness over the spleen. Pressure 
on this caused nausea and vertigo. Then we had 
convulsions, hysterics, coma, enormous polyuria, 
and, at last, among other things, constipation. The 
physician in charge gave me this list of the drugs 
given in four days — night and morning, on each day, 
an ounce of castor oil; at mid-day and bed-time one 
drop of croton oil; three drops had been used in 
one day. The more drugs she took the more she 
demanded, and yet it was impossible to see that the 
doses given caused pain. Meanwhile, for the nurse 
and mother the arrangement for each evacuation 
was the event of the day. A long stomach-tube 
was carried six or seven inches up the bowel, and 
half a pint of olive oil injected; then followed one 
quart to three of flaxseed tea. During the use of 
the enema one person was occupied in compressing 
the anal opening so as to prevent the escape of fluid. 
This help was made necessary on account of the 
great relaxation of the sphincter, into which a thumb 



RECTUM AND DEFECATION IN HYSTERIA. 261 

could be passed without any resistance which could 
be felt to arise from a muscular act. Meanwhile, 
the patient, while insisting on the use of more water, 
was shrieking with pain. The whole affair took two 
to four hours, and the patient was, I thought, the 
least exhausted of those concerned. Sometimes, 
these efforts gave rise to a stool ; sometimes, there 
was none for a week; and, sometimes under the 
wild entreaties of the patient, these trying scenes 
w r ere repeated in the night, nurse and mother being 
aroused to assist. I endeavored to get this girl out 
of the control of her family, but I did not succeed; 
and I believe that her hysteria is now firmly estab- 
lished. 

Want of ability to coordinate the muscles is apt 
to be associated with slight lack of power and more 
or less anaesthesia, but instances of pure incoordi- 
nation as a cause of constipation are very rare. 

The muscles which in action are grouped to effect 
defecation are the respiratory, abdominal, and peri- 
neal, together with those of the intestine. Then it 
is probable that as the act becomes imminent the 
sphincter muscle may become somew T hat relaxed so 
as to make the matter easier. 

Just such a combination of muscle acts is needful 
for phonation, and you will recall my having de- 
scribed cases which owed their aphonic states to 
hysterical incoordination. 

You may see like failures in defecation. The 
bowels may be active, and the respiratory and ab- 
dominal muscles fail to aid them. I have asked the 
nurses to determine this for me, by placing a hand 



262 DISEASES OF THE NEEVOUS SYSTEM. 

on the abdomen and inviting effort, or I have desired 
this test to be applied at the time when effort is 
natural. Sometimes they found either slight action 
or unsustained action. In others, they found none, 
and apparently, just as in phonetic failure, the 
patient knew nothing of her defect, and although 
surprised at having it made plain, did not seem 
much better enabled to correct it. 

Hysterical cases in which the extrusive muscles 
act, but the anal opening declines to yield are most 
rare. They naturally excite suspicion as to being 
due to fissure, but none may be present, although 
the sphincter may still contract violently when an 
effort is made to dilate it from within by the feces, 
or from without by the examining finger. There 
is then a cramp-like pain which does not pass away 
at once, and very persistent retention of feces. 
Aperients cause pain but fail to act efficiently, and 
enemata are driven with violence through a nar- 
rowed anal opening which ingeniously retains the 
feces. 

There are yet other rectal troubles which occur 
in hysteria, and which come and go, are slight or 
severe as the case may be. I refer to pain in the 
rectum, and, of course, I mean pain where there is 
no obvious lesion to account for it, no inflammation, 
piles, or fissure. Your patient, if long enlisted in 
the hysterical ranks, will be pretty sure to have some 
theory as to this pain. It is a " tender ovary — tender 
and much enlarged," or it is "congested," or a 
" womb turned over backwards and blocking the 
whole passage." I quote distinguished female au- 



RECTUM AND DEFECATION IN HYSTERIA. 263 

thorities. At all events, it is a pain descriptively 
decorated with many adjectives. It may come on 
with defecation or not. It may be described as 
caused by sitting or walking. You look in vain for 
a cause, and equally in vain for a means of relief. 
Next to the irritable bladder of hysteria, this is the 
most exasperating of all the minor miseries of this 
disorder. 

I have been reproached by a kindly critic or tw^o 
for not suggesting means of successful treatment 
for all of the various forms of hysterical difficulties 
I have described ; but as regards some of them I 
had little or nothing to say which was not already 
well known, and this was most obvious and true as 
concerns the management of hysterical disorders 
of the rectum and bowels. Their treatment consists 
in dealing with the case as a whole. To rely solely 
upon medicines in such cases as I have described, 
is, as a rule, useless, and I refer now, of course, 
to examples of extreme constipation. In all of these 
some good is to be hoped for from the use of induc- 
tion-currents of electricity, one pole being used 
within the rectum and one on the abdomen. In the 
milder forms of hysterical constipation, I am apt to 
order the well-known pill of aloes, strychnia, and 
belladonna at each meal, and to cease to pay much 
more attention to the bowels than is needed to avoid 
such accumulations as may give rise to piles or 
fissures. 

As to rectal pain without lesion in hysteria, if I 
can exclude the usual known causes of pain, I tell 
the patient her pains will be well when she gets 



264 DISEASES OF THE NERVOUS SYSTEM. 

well, and then cease to allow them to be further 
discussed. 

The anal spasm may be relieved by moderate dila- 
tation, which is preferable to section, since some- 
times that too greatly and too persistently enfeebles 
the sphincter, a most annoying result. 



TREATMENT BY SECLUSION, REST, ETC 265 



LECTURE XVII. 

THE TREATMENT OF OBSTINATE CASES OF NER- 
VOUS EXHAUSTION AND HYSTERIA BY SECLU- 
SION, REST, MASSAGE, ELECTRICITY, AND FULL 
FEEDING. 

The lessons I have here gathered together would 
be incomplete, were I not to add some more detailed 
statement of my views as to the general treatment 
of the conditions out of which arise the varied phe- 
nomena of hysteria. Nothing, I think, can be more 
melancholy than an honest survey of the amount of 
good done in hysteria by the host of drugs which go 
to form the so-called therapeutics of this disease. 
In disorders where time is valuable we may find a 
happy resource in the famous class of antispasmodics, 
but as a rule they are swiftly disappearing from the 
apothecary's prescription files, and the physician of 
our day who is called upon to treat hysteria, or gen- 
eral nervousness or neurasthenia, wisely contents 
himself with a careful estimate of causes, and an 
effort to deal with these by patient treatment 

Perhaps no cases are more common in general 
practice, none more annoying, and none more 
dreaded than those of hysteria, in its infinite num- 
ber of forms and its infinite variety of masquerade. 
The lighter troubles, the spasms, rigors, nervous- 

23 



266 DISEASES OF THE NERVOUS SYSTEM. 

ness, and curious mental states, which haunt the 
times of sexual changes in a woman's life, and espe- 
cially her passage into womanhood, are more or less 
easily dealt with. A careful study of the girl's char- 
acter, of her home surroundings, of the incidents of 
social life, which come with the development of pos- 
sible passion, will be the best guide to treatment, 
and with the obvious indications given us by distinct 
physical ailments, local or general, constitute our 
chief resources. 

But besides these every-day manifestations of hys- 
teria, we meet in practice with a growing class of 
disorders in which change of social circumstances, 
love affairs, disappointments, and what the French 
call vies manquees, combine with physical accidents to 
create invalids, who unite neurasthenic states with a 
bewildering list of hysterical phenomena. These 
are the" bed cases," the broken-down and exhausted 
women, the pests of many households, who constitute 
the despair of physicians, and who furnish those an- 
noying examples of despotic selfishness, which wreck 
the constitutions of nurses and devoted relatives, and 
in unconscious or half-conscious self-indulgence de- 
stroy the comfort of every one about them. 

These are the cases of chronic hysterical invalidism 
which are so difficult to deal with. There must be 
in every country thousands of these unhappy people. 
They weary doctor after doctor, go hopelessly through 
the various cures, and at last end in therapeutic 
inactivity, or find a refuge in homoeopathy, which 
promises a pill for every symptom, and leaves them 
at last where it found them. 



TREATMENT BY SECLUSION, REST, ETC. 267 

It is among such cases that we meet with the 
strange and interesting disorders of which I have 
said so much in these lectures — -disorders which are 
to be met, not by mere symptomatic therapeutics, 
but by a full and clear comprehension of underlying 
causes, and by such treatment of these, whether they 
be moral or physical, as shall destroy the soil in which 
hysteric phenomena flourish. 

You will infer from these few introductory sen- 
tences that I look upon most cases of confirmed hys- 
teria as finally dependent on physical states or defects 
which may first have been directly or indirectly due 
to moral causes, or to these in conjunction with vari- 
ously produced constitutional conditions. Anaemia 
gives rise to lessened power of self-control, this to 
emotional disturbances b and these, in turn, to loss of 
appetite, out of which, if the surroundings be favor- 
able, come graver nutritive disorder and endless 
invalidism. This is a fair sketch of an every-day 
occurrence. It would be waste of time to dilate on 
matters so familiar. 

In grouping cases of hysteria — and remember that 
I speak now of the old and complicated and exasper- 
ating forms of this disorder — there is one reservation 
which I shall have to make, and but one. It refers to 
the small group of women in whom we witness ob- 
stinate hysteria associated with a nearly perfect state 
of physical health. As I recall these cases they have 
usually been women in middle life, and in easy cir- 
cumstances. I know to-day of a dozen or so of such 
people who are able to walk about and to do much 
as they please; women in good condition, flit and 
ruddy, with sound organs and good appetites, but 



268 DISEASES OF THE NERVOUS SYSTEM. 

ever complaining of pains and aches, and liable on 
the least emotional disturbance to exhibit a quaint 
variety of hysterical phenomena. For these women 
there is usually no cure, and you will treat them in 
vain. 

We have, next, hysterical women who are well 
enough to be able to correct the causes of their 
disease by exercise and fresh air; and in this class 
we find abundantly the cases of hysterical joints, and 
all the range of mild hysteric and mimetic symptoms. 
Once make sure that you have such people to deal 
with, and common-sense hygiene, enforced by a reso- 
lute will, and, when you have their confidence, some 
earnestly given moral advice, will be the most they 
will require. Let us put these aside, and we arrive 
at the classes with an allusion to which I began this 
lesson. They are the old and habitually bed-ridden, 
or couch-loving invalids, who are to-day, as they 
have long been, the despair of the best of us. What 
shall we do with them ? 

For practical purposes, we may divide them 
coarsely into two sets : first, the nervous and hys- 
terical woman, who is at the same time fat, but, as a 
rule, anaemic. The class is not a large one, nor is its 
anaemia very profound. As a rule, there is a look 
about the fatness of these women which is anything 
but reassuring. They are more or less feeble, not 
large feeders, and prone to suffer from excessive tire 
upon disproportionate exertion. I have elsewhere 
discussed 1 at length the probability of there being 

1 Fat and Blood. An essay on the Treatment of Neurasthenia 
and some forms of Hysteria. Third edition, 1884. 



TREATMENT BY SECLUSION, BEST, ETC. 269 

chemical differences between the fat of these and of 
more healthy people. There is muscle and muscle, 
fat and fat, and it is now become more and more 
sure that these mysterious variations in the quality 
of tissues, however little we may know of their chem- 
istry, are such important factors in health that we 
cannot at all afford to disregard them. I say all this, 
because, when you meet with women who are at once 
very stout, and not too notably anaemic, you may be 
disposed to regard them too lightly as free from sus- 
picion of any such grave nutritive disorders as may 
seem to offer reasonable explanation of their nervous 
symptoms. Those who are very plainly pallid and 
flabby, fat and feeble, will, I may here say, offer, like 
the rest of their class, a problem not always very 
easy to solve. We shall, by and by, consider how 
they are to be dealt with. 

There remains, in the second place, the larger class 
of nervous, and exhausted, and hysterical women 
who are, as a rule, weak, pallid, flabby, disfigured 
by acne, or at least with rough and coarse skins; 
poor eaters ; digesting ill ; incapable of exercise, and 
suffering from the cold extremities which lack of 
this, with thin blood, occasions. They lie in bed, 
or on sofas, hopeless and helpless, and exhibit every 
conceivable variety of hysteria. 

It has been for some years my custom, when in 
these women every other plan has failed, to deal with 
them by a certain combination of therapeutic means 
which has now been securely tested by time and 
hundreds of successes. It has stood the criticism 
and won the approval of many competent physicians, 

23* 



270 DISEASES OF THE NERVOUS SYSTEM. 

who have found in it a resource where all else had 
failed. As it is now seven years since I first pub- 
lished 1 a formal statement of this method, it seems 
to me that the time has come when I should say in 
what respect my opinions have been altered or con- 
firmed, and what changes I would desire to suggest. 
I shall, therefore, give here a condensed statement of 
the treatment in question, and referring to my for- 
mer publications for minute details, shall criticise it 
in the light of what, without want of modest state- 
ment, I may venture to call an enormous experience. 

The treatment to which in these pages I so many 
times refer, consists in an effort to lift the health of 
patients to a higher plane by the use of seclusion, 
which cuts off excitement and foolish sympathy; hy 
rest, so complete as to exclude all causes of tire ; by 
massage, which substitutes passive exercise for exer- 
tion; and by electrical muscular excitation, which 
acts in a somewhat similar manner to massage, and 
with it by depriving rest in bed of its essential evils, 
leaves only its good. These means allow us to over- 
feed our patients, and to enable them to digest with 
ease large amounts of food. 

I have here put first the idea of seclusion. That 
means separation from indulgent friends and sympa- 
thetic relatives. It is a change in the interest of 
every one concerned, because a chronic invalid is a 
slow poison in a household of loving people. It 
means, too, the breaking up of old habits; and it 
means, usually, a change of diet and personal sur- 

1 Rest in the Treatment of Disease. Seguin series of Lectures. 
Appleton & Co., New York. Eat and Blood, 1877. 



TREATMENT BY SECLUSION, REST, ETC. 271 

roundings, because seclusion is not often to be at- 
tained at home. For nervous or hysterical people it 
must be absolute ; for merely feeble people, who re- 
tain the power of self-control, and who are to be put 
at rest, it admits of every degree of liberality. We 
should remember, however, that even if a woman be 
only a tired and weak invalid, and not a very ner- 
vous one, she must, owing to the necessities of the 
treatment, see daily the masseuse, the electrician, 
the nurse, and the physician, so that to admit other 
visitors is to make a needless call upon her growing 
strength, which in these cases is sorely taxed by con- 
versation. I do not say that seclusion is impossible 
in the home of the invalid, for I have obtained it 
with success many times, when my nurse was a thor- 
oughly good one; but the other plan of securing it 
by a change of dwelling is better and far easier. 
Seclusion, of course, has for its objects the cutting 
off of many hurtful influences; but, above all, it 
means the power of separating the invalid from 
some willing slave, a mother or a sister, whose serf- 
dom, as usual, degrades and destroys the despot, 
while it ruins the slave. Like all rules, this latter 
one of isolation from habitual personal relations, 
has its exceptions. I have had cases nursed suc- 
cessfully by a mother or a sister, but I never wish to 
make the experiment, because it inevitably makes 
heavier the doctor's task, and because it is nearly 
always an experiment. Get your patient alone with 
a good nurse, with some woman who is trained, in- 
telligent, young, and clever enough to read aloud, 
and with culture enough to make her an agree- 



272 DISEASES OF THE NERVOUS SYSTEM. 

able companion. Ten years ago there were few such 
nurses; to-day there are enough of them; but in 
choosing a nurse, remember that if she has no tact, 
or has a short temper, or is clumsy, or unneat, you 
may have your case spoiled, or be forced to change 
the nurse midway in your treatment; but, at all 
events, never hesitate about this. If the patient 
and nurse do not agree, make a change, and, if need 
be, another. I cannot enough emphasize this matter 
of the nurse. Put yourself in the place of an intel- 
ligent lady shut up for two months with a coarse 
woman, whose talk and whose habits disgust, and 
doubly disgust, because the victim is emotional and 
sensitive by nature and by habit, and you will realize 
the need for care in your choice of an attendant. Mere 
technical training will not answer, and I have seen 
an utterly untrained woman, of good brains and tact, 
win successes which are sometimes denied to the 
best educated nurses who lack those ever-needed 
moral qualities which no training and no length of 
experience will give to some women. 

And now, having your patient isolated and the 
nurse in charge, certain grave questions arise. We 
will presume that the case has been found to be 
suitable, and that the patient has come within your 
own control — whether at her home or elsewhere — 
that her case is new r to you, and that you have de- 
cided to use rest. The first question you will have 
to settle is as to whether it be wise when using this 
treatment to correct all womb troubles at once, or 
to wait, or to neglect them altogether? I am guided 
as to these matters by the following rules: In the 



TREATMENT BY SECLUSION, REST, ETC, 273 

case of married women, I make or cause to be made 
a thorough examination to begin with. If there be 
only congestive states and their consequences, I trust 
to the general treatment for cure. If there be 
marked displacements or excessive menstruation, I 
like to correct the one and have the uterus well 
searched for possible causes of the other. Should 
there be grave fissures of the neck of the w^omb or 
perineal rupture, I prefer to have these relieved at 
once if the patient be in a moderately good state, 
but if the case be one of extreme feebleness, I like 
to delay all surgical intervention until the improved 
conditions w T hich follow my treatment offer a better 
chance of successful mechanical interference. If 
the patient be a virgin, and there seems little reason 
to suspect misplacements, I trust again to the gen- 
eral treatment. If, moreover, there be plain evidence 
of misplacement, and the patient be of that tempera- 
ment which makes vaginal examinations disastrous 
shocks to the nervous system, I w r ait patiently the 
result of the rest and its aids. Then, at the close of 
two months I like to make an effort at local relief, 
in the hope that with a reinforced nutritive life my 
patient may bear the strain. Dr. Goodell will re- 
member cases, seen with me, in which the patient, 
having retroversion, decided to undergo no mechani- 
cal treatment, and has seemingly become and re- 
mained well, under rest, etc., despite the uterine 
trouble. 

Misplaced ovaries cause in my experience a great 
deal of trouble, but both Prof. Goodell and I have 
seen a number of cases in which this annoying com- 



274 DISEASES OF THE NERVOUS SYSTEM. 

plication righted itself spontaneously during treat- 
ment by rest. In one of these cases, the misplace- 
ment was so extreme and the symptoms caused by 
it so grave that the propriety of double ovariotomy 
was more than once discussed. We were pleasura- 
bly surprised as the treatment progressed to find a 
gradual slipping upwards of the ovaries until at 
last they regained their usual place. This change ac- 
companied a remarkable gain in vigor and in flesh. 
I have never yet been able to make clear to myself 
precisely why under these circumstances the ovaries 
should be drawn up, but Prof. G-oodell's opinion in a 
matter of this kind must be far better than mine, and 
as he thinks there is a competent physical explanation , 
I give his remarks in full : " The ovaries should be 
daily replaced by atmospheric pressure, the knee- 
breast posture, and the result is that they finally go 
up to stay up. Under the influence of the general 
gain in health, and the local handling of the mas- 
seuse, the organs cease to be congested. Then the 
increased deposit of fat in the abdominal walls, in 
the omental apron, and around the abdominal vis- 
cera, to say nothing of the needful fat-padding in 
all the pelvic nooks and crannies, increases the re- 
tentive power of the abdomen. 1 " 

"By its gravity the now fat-laden and overhang- 
ing wall of the abdomen tends to draw toward itself, 
that is to say upward, the movable wall of the pelvis. 
The behavior is like that of a half-filled India-rubber 
ball, in which bulging at one portion causes a corre- 
sponding cupping at another." 

1 Lessons on Gynecology, Goodell, p. 116. 



TREATMENT BY SECLUSION, REST, ETC. 275 

You are now ready to put your patient at rest in 
bed, and you will not, I trust, despise any details 
which will make rest endurable and useful. You 
cannot always get, but you can desire to get, sun- 
shine, an open fireplace, a well-made bed, and a 
lounge for change. 

Rest means with me a good deal more than merely 
saying " Go to bed and stay there. " It means care 
that letters bring no worrying news, that they are 
brief and of such kind as a nurse may read aloud. 
It means absence of all possible use of brain and 
body. It means neither reading nor writing, at 
least for a time, with exceptions in cases where, as 
is rare, there is no asthenopia. If the nurse can 
read to the patient, and reading be borne without 
fatigue, let it be used at first for only a few minutes 
at a time. If this wearies, then let the nurse try to 
cull the bits of interesting news from the papers, 
and as she glances over the columns talk this to the 
patient instead of formally reading aloud. Why 
this tires less than reading I do not know, but that 
it does so I am sure. If you are disposed to smile 
because I say let the nurse feed the patient, you will 
not, if, lying supine, you make the experiment of 
using your own hands in this act of feeding. Or 
even if seated in bed you do this, you will find that 
the effort is singularly tiresome. I believe I have 
done something to make rest fashionable among 
physicians as an essential in the treatment of spinal 
maladies, and both in them and in the treatment of 
neurasthenia and hysteria it is well that you clearly 
comprehend what it is that I mean by rest. Your 



276 DISEASES OF THE NERVOUS SYSTEM. 

trouble will be always that the patient will desire to 
lie on a sofa, or to make some such compromise, 
but in bad cases, and it is only of these I speak, all 
this is but mere trifling, and you had better, on the 
whole, make an error in the direction of a too abso- 
lute rest. 

The moral uses of enforced rest are readily esti- 
mated. From a restless life of irregular hours, 
from hurtful sympathy and over-zealous care, the 
patient passes into an atmosphere of quiet, of 
orderly control, and under the care of a thorough 
nurse. The result is always at first, whatever it 
may be afterwards, a sense of relief, and a remark- 
able and often a quite abrupt disappearance of many, 
of the nervous symptoms which had previously 
harassed the patient. With this first sense of ease 
comes the precious chance of the doctor for moral 
medication. He can now point out that, however 
hard it was with failing powers to control emotion 
and suppress nervousness, it is easy to do all this 
when the physical condition is improving. This 
doctrine will be aided and enforced by the nurse if 
a good one, and your patient will be constantly re- 
minded that she is getting better physically, and is 
expected to accomplish more and more in the way 
of self-restraint. If she fails, you praise the effort. 
If she succeeds, you applaud the success. You are 
her whole audience, and this with a hysterical girl 
gives you great power. Why rest is of therapeutic 
value I have elsewhere more fully shown. It is of 
more use here to urge that, like all medication^ it 
has its evil side, and that it is to the other parts of 



TREATMENT BY SECLUSION, BEST, ETC. 277 

this system we must look for the means of over- 
coming and counteracting them. Ordinarily, pro- 
longed rest enfeebles circulation, weakens digestion, 
lessens appetite, and constipates the bowels. Mus- 
cles in action serve practically as small hearts for 
themselves and the localities about them. Imagine 
their activity suppressed for a time, and remember, 
too, that the heart in a person at rest loses twenty 
beats a minute, and thus adds to the passive mischief. 
Moreover, the liver and the double abdominal circu- 
lation, and the moving bowels cease to have the 
constant stimulation which they get when w T e are 
afoot, and so in many ways damage is done. Rest 
then is, or may be, hurtful. We turn to massage and 
electricity for aid in correcting this. Massage, or 
kneading of the muscles, has been long used in 
Europe and the East. It is the "shampooing" of 
the Oriental, the "lammi lammi" of the Sandwich 
Islander. I do not know that it has been used except 
under my orders as a systematic daily mechanical 
tonic. For details of just how it ought to be done, 
and with what caution, and how long and what are 
the immediate physiological effects, I must again 
refer to my book on the "Treatment of Neurasthenia 
and Hysteria." Used daily, from half an hour to an 
hour, it is a pleasant and refreshing process, and 
even when, as does happen, it seems at first to tire, 
all of this result, soon or late, passes away. 

It substitutes exercise for exertion, and does nearly 
all that a moderate amount of active muscular mo- 
tion can do in the way of warming the limbs, 
increasing the blood-flow, stimulating the local cir- 

24 



278 DISEASES OF THE NERVOUS SYSTEM. 

dilations, and reddening the skin. It may, and 
should, at last, be a pretty violent influence, and, 
by and by, may be used in such a way as to jog the 
intestines like the invaluable shaking given by a 
rough trotting horse. To be thoroughly done, it 
needs a trained masseuse, but any clever person, 
who is strong enough, may easily learn to do it; 
and it enables one daily to rub into the skin a large 
amount of some nourishing oil, like that of the olive 
or the cocoanut. You will meet with some difficulty 
in having the back kneaded when there is spinal irri- 
tation, but as to this you must be relentless ; and the 
masseuse, by degrees approaching the sore spots, will 
in time come to treat them as thoroughly as any other 
part, and with the sure result of, by and by, lessening 
and destroying the local sensitiveness. In like man- 
ner, the hyperesthesias of other regions maybe dealt 
with, and, above all, that which is sometimes a truly 
ovarian, and sometimes merely an abdominal surface 
sensitiveness, may, with time and cautious patience, 
be relieved or cured. 

I never could see why a tonic so valuable as this 
should be left to assist the triumphs of the charlatan ; 
and I feel that, in making it of easy use, I have done 
that which, in many ways, is valuable to the surgeon 
and the physician. 

Massage is, in these cases, absolutely essential; 
electricity is very desirable; but we can, in many 
cases, do without it. 

It involves the daily use of induction-currents 
(slow interruptions) to almost every muscle which 
can be reached; the object being to throw each 



TREATMENT BY SECLUSION, REST, ETC. 279 

muscle into decided contraction. Finally, a mild 
current with rapid breaks should be made to pass 
from the neck to the feet for fifteen minutes. That 
it is, thus used, a powerful tonic I have not the 
faintest doubt, and I commonly employ it with 
massage, except where the need to save expense is of 
moment. 

These means are valuable to prevent rest from 
being hurtful, and to enable us to fatten and redden 
the patient by a methodical system of over-feeding, 
w T ith the use of proper tonics. I have already said 
that there is some trouble in treating fat and anaemic 
women. You may cure them by ordinary means, 
but it is easiest and safest to do so by putting them 
at rest, and under-feeding with milk, so as, at first, 
materially to reduce the flesh, after which the patient 
may be subjected to the usual treatment by massage 
and the other means I have detailed. It is easy, 
with perfect security, to lessen the fat rapidly, if 
only the patient be kept in bed; otherwise, as we 
have too well known, it is a dangerous and difficult 
thing to effect. I may add that if there is much, or 
a very obstinate dyspepsia, it is well to begin the 
treatment of any case by Card's milk treatment. 
It is astonishing how this simplifies matters, and how 
often under milk, massage, and rest the whole train 
of nervous ills melts away in a few days: and how 
we are able to dispense with chloral and morphia, or 
habitual use of other drugs. Indeed I may add that 
I should be sorry, now-a-days, to treat any old case 
of the opium habit without these invaluable aids. 1 

1 Am. Journ. Med. Sci., Oct. 1866. 



280 DISEASES OF THE NERVOUS SYSTEM. 

In fact, if I have the least doubt, I never fail to 
begin treatment by rest, with milk as the sole diet ; 
while, of course, there are also many cases where it 
is used only as an adjuvant, and I simply feed the 
patient in the ordinary manner. By some such 
plan the patient has the diet gradually increased, 
until it is common to see her take three meals as 
well as two quarts of milk, six to nine ounces of 
Hoff's fluid malt, and a variable amount of raw 
soup between meals and at bed- time. 

Iron in large doses, alcohol rarely, and cod-liver 
oil, by the mouth or rectum, when well borne, are to 
be added as indicated. 

The result of two months of such treatment, in 
pale, bloodless, meagre, and nervous women, must 
be seen to be believed or duly appreciated. You 
have seen it here often enough to understand me 
fully. Each and all of the means described are to be 
slowly and by degrees laid aside, and then you have 
as carefully to get your patient up and afoot. Of 
late, I have been in the habit of preparing for this 
by allowing the nurse or masseuse to exercise the 
patient, while in bed, with a series of slowly executed 
Swedish gymnastics, which are continued in a modi- 
fied form, when the patient gets up. If this be well 
and pleasantly managed, it is both agreeable to the 
patient and a valuable means of training the muscles. 

I have elsewhere shown that massage is followed 
by an increase in the rate of elimination, and more 
recently Dr. Peter Alexander Young 1 has published 
analyses of great interest, which prove the immense 

1 Edin. Clin, and Path. Journ., August, 1884. 



TREATMENT BY SECLUSION, REST, ETC. 281 

daily increase in the secretion of urea during rest 
treatment. He says : " The kidneys might be ex- 
pected to suffer under the strain of the elimination 
of the enormously increased quantity of urea, but 
I have not found this to be the case. I have esti- 
mated the quantity of urea passed in twenty-four 
hours, and find it was as follows : 









FIRST CASE. 




Dayjof Grs. of Urea in 


Ozs. of Uri 


Treatment, 24 hours. 


24 hour 


1st . 


. 220 


16 


5th 












221 


28 


10th 












639 


53 


15th 












602 


50 


20th 












823 


64 


25th 












770 


64 


30th 












746 


62 


35th 












722 


60 


39th 












. 607 


62 


SECOND CASE. 




Day of Grs. ot Urea i n 


Ozs. of Uri 


Treatment. 24 hours. 


24 hour 


1st . . 141 


10 


3d 












274 


16 


5th 












278 


20 


10th 












420 


30 


20th 












520 


38 


30th 












575 


42 


40th 












875 


68 



"That this largely increased quantity of urea was 
chiefly derived from the nitrogenous food taken, and 
not from the muscular waste, would be anticipated 

24* 



282 DISEASES OF THE NERVOUS SYSTEM. 

from the researches of Fick and Wislicenus and 
others. I found, in the first case, that on the four- 
teenth day after the usual full diet and three hours' 
massage, with thirty-five minutes' electricity, the 
urea amounted to 650 grains in twenty-four hours, 
and on the seventeenth day, after three days' cessa- 
tion from rubbing and electricity, with the same 
diet, the urea passed was 698 grains in twenty-four 
hours." 

Dr. Wm, W. Keen has recently shown that in a 
case of albuminuria where the albumen disappeared 
entirely with rest and reappeared with exercise, the 
most extreme massage had no such influence as 
physical exertion. This curious and interesting fact 
suggests to us that the difference between exercise 
and massage must be far greater than has been sup- 
posed, and that probably the latter does not raise the 
blood-pressure as does the former. 

The final results of all this treatment when it suc- 
ceeds are reasonably to increase the bulk of the 
body, to improve the moral and physical tone, and 
to cure the aneemia. These changes are obvious in 
some degree early in the case, the flesh shows first 
in the face, and the gain in blood in the pink of the 
finger-nail, which I am apt to watch and note. I 
have been many times asked if these amendments 
or cures are permanent, and I believe I am now, 
after a careful review of some hundreds of cases, 
fully able to say that they are quite as lasting as the 
cures of any nutritive defects obtained in more ordi- 
nary ways. It is a plan never, in my opinion, to be used 
where exercise, outdoor life, tonics, or change have not 



TEEATMENT BY SECLUSION, BEST, ETC. 28 

been thoroughly tested; but where these have failed it 
leaves us with a novel resource without which no 
case of broken constitution, nervousness, or old hys- 
teria should be left to hopeless invalidism, and to a 
life in bed, or on a lounge. I never use it if I can 
do without it; but in well-chosen cases I use it with 
a confidence which has become alike courageous and 
habitual. 



INDEX. 



ALBUMINURIA, effects of 
ix massage in, 282 
Alternate spasms, 127 
Anal spasm, 262 
Anaemia with excess of fat, 268 
Anaesthesia of rectum, 258 
Anorexia, hysterical, 242 
Aphonia, hysterical, forms of, 

208, 211 
Ataxia, hysterical, 39 

description of, 40-43 
of one limb, 48 
of respiration, 215 
treatment of, 45 
Athetosis, hysterical, 110 
Atropine, injection of, 109 
Autobiography of hysteria, 88 



Chorea in the black, 151 
in Philadelphia, 151 
mimicry of, 74 
recurrence of, 146 
relation of, to climate, 148 
to locality, 150 
to palpitation, 149 
to weather, 144 
season of, 138 
varieties of, 154 
Choreal habit, 156 
Chronic spasms, 123 
Coeducation, defects of, 14 
Constipation, incoordination a 

cause of, 261 
Crutch cane, 47 



TVEttQUET'S ataxia, 39 



CASE of excessive fasting, 244 
of hysteria with organic dis- 
ease of spine, 228 
of hysterical joint with extra- 
capsular organic changes, 
220 
of irritable rectum , 255 
of paralysis of rectum, 260 
of rapid respiration from 
wound of chest, 201 
Chorea of childhood, 137 
deaths from, 151 
Gerhard on, 138 
in Chicago, 151 



DEFECATION in hysteria, 
252 
Deglutition in hysteria, 240 
! Diarrhoea, scybalous, 253 



I^LECTEICITY, 278 
j Emotion, defects of, in hys- 
terical paralysis, 35 
I Epidemic imitative chorea, 75 



FASTING, excessive, 244 
simulation of, 91 



GOODELL on ovarian displace- 
ment, 274 



286 



INDEX. 



HABIT, chorea, 156 
treatment of, 162 
Hirsch on relation of chorea to 

climate, 148 
Hemiplegia, crutch for, 48 
hysterical, 24 
double, 31 
Hunter, effects of attention on 

body, 60 
Hysteria, aphonia of, 208 
ataxia of, 39 
autobiography of, 88 
causes of, 14 
death in, 23 

defects of sensation in, 26 
deglutition in, 240 
forms of, in America, 239 
gastro-intestinal disorders of, 

238 
heart in, 185 
hemiplegia of, 24 
oedema of, 28 
of the joints, 218 

with organic changes, 
225 
paralysis of, 13 
paraplegia of, 17 
ptosis of, 134 
pulse in, 190 
reflexes in, 26-27 
respiration in, 199 
respiratory, ataxia of, 215 
treatment of, 265 
vaso-motor, disorders of, 184, 

191 
with organic disease of spine, 
227 
Hysterical anorexia, 242 
ischemia, 192 
paresis, 50 
regurgitation, 241 



INCOORDINATION, a cause 
1 of constipation, 261 
Imitation, unconscious, 62 
Imitative chorea, epidemic of, 

75 
IschaBmia, hysterical, 192 
in organic analgesia, 193 



j 



OINTS, hysterical, 218 



K 



EEN, Wm. W., 282 



LEWIS, Morris J., chorea, 139 
Local spasms, section of ten- 
dons in, 128 



MASSAGE, 277 
effects of, in albuminuria, 
282 
Milk, use of, 279 
Mills, chorea, 139 
Mimicry of chorea, 74 
of disease, 55 
causes of, 56 



i VTERVOUSNESS, cardiac, 187 
| 1\| general, 57 
Night palsy, 182 



/17DEMA, hysterical, 28 

\th (Esophageal vomiting in 

hysteria, 240 
Ovaries, displacement of, 273 
1 Ovarian hysteria, ovarian ten- 
derness in, 27 



PAGET, Sir James, mimicry of 
disease, 55 
effects of attention on body, 
60 
Pain, relation of, to weather, 145 
Paralyses of hysteria, treatment 
" of, 20 
hysterical, 13 

electrical reactions in, 
28 
of childhood, [relation to 

weather, 146 
of rectum, 256-259 
Paraplegia, hysterical, 17 



INDEX. 



287 



Paresis of hysteria, 50 
Phantom tumors, 108 
Ptosis, hysterical, 134 



T) ACE, relation of, to chorea, 
II 151 

Rectal pain, 262 
Rectum, anesthesia of, 258 
in hysteria, 252 
paralysis of, 256-259 
the irritable, 254 
Reflexes in hysterical paralysis, 

26-27 
Regurgitation in hysteria, 241 
Respiratory disorders of hysteria, 
199 
failure, sleep, 183 
Rest, 275 

treatment, secretion of urea 
during, 281 
Rufz on relation of chorea to 
climate, 148 



QCHAFFER on mimicry of 

U disease, 55 

Seclusion, 270 

Secretion of urea during rest 

treatment, 281 
Sensation, defects of, in hysteria, 

26 
Sensory discharges, aura of, 171 
forms of, 167 
in sleep, 163 
treatment of, 171 
Simulation of fasting, 91 
Sinkler Wharton, paralysis of 

childhood, 146 
Skey, on mimicry of disease, 55 
Sleep, disorders of, 163 

failure of respiratory centres, 
183 



Sleep, hemiplegia of, 181 

local spasms in, 180 

sensory discharges in, 163 
Spasms, alternate, 127 

athetoic, 110 

chronic, 123 

functional, 103 

local, of great pectoral mus- 
cle, 107 

of anus, 262 

permanent, 124 

simulation of, 130 

rotatory, 97 

rhythmical, of gastrocne- 
mius, 109 

unusual forms of, 96 



TABLES of chorea, 140 
Tendons, section of, 128 
Treatment of gastro-intestinal 
disorders in hysteria, 243 
of hysteria, 265 
of hysterical rectum, 256 
Tumor, 114 

emotional, 115 
forms of, 117 
phantom, 108 
Tremors, alcoholic, 121 
local, 119 



TTTERUS, in hysteria, 272 



yASO-MQTOR disorders in 
V hysteria, 184 
Vomiting, hysterical, 82 
imitative, 63 
oesophageal, 240 
Yon Ziemssen on relation of 
chorea to climate, 148 



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